Every finding on record at Red Bluff Health Care Center

Based on interview and record review, the facility failed to ensure residents who were incontinent (involuntary loss of control) of bladder were assessed and provided appropriate treatment and services to maintain or improve continence to the extent possible for one of five sampled residents (Residents 1) when:1. Resident 1 did not receive a bowel and bladder assessment as needed (PRN).2. The Interdisciplinary Team (IDT, a group of healthcare disciplines that develop plans of care) did not re-evaluate Resident 1's incontinent status after changes in urinary status and update care plan as indicated.These failures had the potential to contribute to residents' decline or lack of improvement in urinary continence and or loss of bladder control and function.Findings:1. A review of the facility's policy titled, Bowel and Bladder Management Program, dated 10/21/2010, indicated Purpose to ensure that a resident who is incontinent of bowel and bladder receives the necessary care and treatment. 2. A bowel and bladder assessment form shall be completed on all residents with identified incontinence problems within 14 days of admission and PRN. 8. The IDT will review residents' incontinence status on admission and re-evaluate at least quarterly using the RAI-RAP guidelines. 9. Licensed Nurses and/or IDT will update care plans when indicated by a change in status.A review of Resident 1's clinical record indicated he was admitted to the facility on [DATE] with diagnoses that included depression, personality disorder (mental health condition where a person's way of thinking, feeling and behaving is very different from what is considered typical and these patterns are long lasting and hard to change) and anxiety.A review of Resident 1's Urinary care plan with a date initiated 2/24/26, indicated Resident 1 had an indwelling urinary catheter (a tube inserted into the bladder to drain urine), and urinary retention related to neurogenic bladder (nerves that tell the bladder when to hold urine and when to empty are not working properly causing trouble controlling urination or fully emptying their bladder). A review of Resident 1's admission Minimum Data Set (MDS, a standardized resident assessment), dated 3/9/26, indicated Resident 1 was cognitively intact (able to think and reason). Section H Bowel and Bladder status indicated Resident 1 had an indwelling urinary catheter.A review of the bowel and bladder assessment, dated 3/4/26, indicated Resident 1 had an indwelling urinary catheter and was incontinent of bowel (cannot fully control their bowel movements). Resident 1 required assistance in getting to the toilet, managing clothing and cleaning self after toileting.A review of Resident 1's Physician Orders for March/April 2026, indicated no orders for the removal of the foley catheter.During a review of a Health Status note dated 2/24/26 at 8:35 pm, Resident 1 complained of abdominal pain and had bladder distention (bladder has become stretched or swollen because it is holding too much urine). The note indicated that Resident 1 had not been able to urinate after his urinary catheter was removed that morning. Resident 1's doctor (MD) was notified and gave orders (instructed) Resident 1's urinary catheter be reinserted. A review of Resident 1's physician orders dated 2/24/26, indicated, Insert 16-Fr [French, a universal measurement for diameter of medical tubes) Foley catheter [brand name of a urinary catheter].A record review of Resident 1's History and Physical (H&P), written by MD on 2/24/26, indicated a diagnosis of urinary retention (an inability to empty one's bladder completely).A record review of Resident 1's Physician's Orders, dated 4/3/26, indicated to discontinue (stop) the 16-Fr urinary catheter with a start date of 4/9/26.A review of the physician order dated 4/3/26 indicated Flomax (a medication to help improve urine flow and reduce urinary retention), 0.4 milligrams (mg, a unit of measure), give one capsule by mouth at bedtime.During a review of a Health Status note dated 4/8/26 at 10:27 pm, indicated the Resident 1's urinary catheter was discontinued per the physician's order and that Resident 1 will be monitored to ensure he was able to urinate. A review of Resident 1's Bowel and Bladder assessments showed that no bowel and bladder assessments were done after the urinary catheter removed. During a review of a Health Status note dated 4/9/26 at 10:33 pm, documentation reflected that Resident 1 continued to state he was not able to use the urinal. During a review of a Health Status note dated 4/10/26 at 6:54 am, documentation reflected that Resident 1 has refused multiple times to go to the bathroom to be toileted. During a review of a Health Status note dated 4/11/26 at 9:12 am, documentation indicated that Resident 1 continued to state that he does not know how to use a urinal and that education was provided. During a review of a Health Status note dated 4/11/26 at 12:29 pm, documentation reflected that nursing staff were made aware that Resident 1 had not urinated since the morning. Upon nursing assessment, Resident 1's bladder felt full. The Director of Nursing (DON) was notified about what to do next. Then while getting ready to get Resident 1 to the bathroom, he urinated a large amount and the nurse determined that Resident 1's bladder felt less full. Resident 1 has expressed at that time, he wanted his urinary catheter put back in and his MD was notified, but gave no new orders. During a review of a Health Status note dated 4/12/26 at 9:29 am, documentation reflected that Resident 1 continued to state that he does not know how to use a urinal and was re-educated. During a review of a Health Status note dated 4/12/26 at 11:11 am, a Licensed Nurse (LN) was called into Resident 1's room by nursing staff. Resident 1 was yelling and complaining of not feeling well and not being able to urinate. This nurse palpated on the resident's bladder and resident started urinating. Asked resident if he felt any better. Resident 1 then stated he did not feel better and that he would like his catheter back. The nurse then suggested that Resident 1 should use the toilet and feel relaxed to be able to empty bladder completely. During a review of a health status note dated 4/17/26 at 7:28 pm, the LN was called into resident's rooms CNA staff was taking vitals and residents blood pressure was 78/42 and Resident 1's feet were noted to be at a 45-degree angle and head of bed was lowered. Resident 1 was then assisted up, head at a 90-degree angle and feet lowered and vital signs went up 110/60, and Resident 1 stated that he felt better. Resident 1 stated that his mouth felt dry. MD was notified at approximately 5:20 pm and MD stated that he had seen Resident 1 earlier in the day and Resident 1 stated to him that he also felt unwell and that he was concerned of feeling he had a full blader. MD explained solutions to Resident 1 who cut him off and stated that every time he does something for him it never works and makes him feel worse. Resident 1 refused MDs help. Resident was then asked if he would like to receive assistance from MD to which he stated (NO LEAVE ME ALONE). A review of a health status note dated 4/17/26 at 9:56 pm, Resident 1 being monitored due to behaviors, resident has been making sad statements that he wants to die. Resident 1 refused all medications from this LN, stating that taking his medication will make him sick. Resident 1 verbalized not feeling well but does not want help from this LN or MD here. Resident 1 verbalized not wanting to go to hospital either stating I don't trust them. A review of a health status note dated 4/18/26 at 12:34 pm, Resident 1 being monitored due to behaviors. Resident 1 has had no behavior, but is requesting to go to hospital, but has no reason for needing to go. He is in no distress, will continue to monitor. During a review of Resident 1's hospital records was transferred to an acute care hospital with an admit day of 4/19/26, Resident 1 was discharged 8 days later 4/27/26 with a final diagnosis of septic shock (a life-threatening condition that happens when a serious infection overwhelms the body and causes blood pressure to drop dangerously low). kidney injury caused by septic shock. Catheter associated urinary tract infection (bacterial infection develops in someone who has a urinary catheter in place or recently had one) on admission and uremic encephalopathy (severe kidney failure causing toxins to build up in the body, affecting brain function and leading to confusion or decreased alertness). During an interview 5/29/26 at 11:48 am, Licensed Vocational Nurse (LVN)1 stated Resident 1 came to facility with a foley catheter then later had it removed. LVN 1 stated if a resident mentioned increased pain, had increased behaviors or feeling like he had a full bladder after urination, the process was to call the physician. LVN 1 stated the only way to know if there was still urine in the bladder was to do a straight catheter (tube inserted into bladder only long enough to drain bladder). LVN 1 stated a physician order for a urinalysis (laboratory testing for an infection) may be needed.During interview 5/29/26 at 12:51 pm, Certified Nursing Assistant (CNA), stated Resident 1 had a urinary catheter removed, and had hard time adjusting. CNA stated Resident 1 was not feeling well but physician talked to him within the week. CNA stated before Resident 1 was transferred to the hospital for evaluation he acted differently when he knocked over his juice, looked weaker and was not as active.During a phone interview 6/1/26 at 9:47 am, LVN 2 stated Resident 1 complained about difficulty in urinating. LVN 2 stated when Resident 1 was asleep and relaxed, he would urinate further stating she felt like maybe he was too tense while awake to be able to urinate.During a phone interview 6/4/26 at 12:15 pm, LVN 3 stated Resident 1 had a foley catheter that was discontinued. LVN 3 stated Resident 1 would complain that he couldn't urinate and that they were hurting. LVN 3 stated he called physician and received an order to place the urinary catheter back in. LVN 3 stated Resident 1 complained about his care and not being able to urinate.During concurrent interview record review on 6/9/26 at 11:07l am, Director of Nursing (DON), stated once the urinary catheter was discontinued a new bowel and bladder assessment would be expected to be done. DON confirmed there was no nursing documentation that nursing staff were monitoring or tracking how often he urinated once the catheter was removed. DON explained Resident 1 would hold his bladder until he fell asleep and then urinated due to being relaxed. Reviewed bowel and bladder elimination documentation DON confirmed Resident 1 was voiding (urinate) and not voiding. DON stated there were some clinical signs and other assessments that could have been done and a new care plan to address bladder retraining.

Based on interview and record review the facility failed to ensure one of five sampled residents (Resident 1), had a behavioral health evaluation and services to meet psychiatric behavioral needs.This had the potential for Resident 1 to be at risk for worsening psychiatric symptoms, decline in their physical, emotional, and psychosocial well-being and unmet mental health needs.Findings:A review of a facility policy titled Behavior Management and Documentation of Behaviors: dated 9/1/2008, indicated B. Implement Interventions to Alleviate Possible Causal Factors. 7. Identify the additional resources if residents do not respond to usual interventions and forward slash or medications through the interdisciplinary team process comma case managers etc. C. Evaluate Outcome of Non-Drug Interventions 8. Review residence behavior symptoms and response to medication during the IDT and more often if indicated. Document all assessments, interventions and outcomes in the medical record.A review of Resident 1's clinical record indicated he was admitted to the facility on [DATE] with diagnoses that included personality disorder (mental health condition where a person's way of thinking, feeling and behaving is very different from what is considered typical and these patterns are long lasting and hard to change), other specified depressive episodes and anxiety.A review of the admission Minimum Data Set (MDS, a standardized resident assessment), dated 3/9/26, indicated Resident 1 was cognitively intact (able to think and reason).A review of the preadmission screening and resident review (PASRR, identifies residents with serious mental illness) dated on 2/24/26 indicated Resident 1 triggered for a Level II assessment which helps determine placement and mental health specialized services. No documentation in record for the level II screening being completed.During a review of physician orders dated 2/24/26, indicated two separate orders for Resident 1, may have psychology and psychiatric consult with follow up and treatment as needed. There was no documentation found in the record of a referral for either consultation.A review of the care plan initiated 2/26/26 indicated Resident 1 has a behavior problem of frequent calling out, yelling at staff, frequent concerns that have been addressed refusal of care. Interventions: Administer medications as ordered, monitor/document for side effects and effectiveness, anticipate and meet the needs of the resident, caregivers to provide opportunity for positive interaction, attention, stop and talk with him as passing by, explain all procedures to the resident before starting and allow resident to adjust to changes, if reasonable, discuss the residents behavior, Explain/reinforce why behavior is inappropriate and or unacceptable for resident, minimize potential for residents disruptive behavior by offering tasks which divert attention such as activities, snacks, TV, fresh air, etcetera.A review of the care plan date initiated 2/26/26 indicated Resident 1 has a behavior problem in effective coping related to maladaptive (not helpful, effective or supportive of healthy functioning) thinking patterns. Interventions: Administer medications as ordered, Monitor/document for side effects and effectiveness, anticipate and meet the needs of the resident, assist the resident to develop more appropriate methods of coping and interacting, encourage positive self-reflection encourage the resident to express feelings appropriately, caregivers to provide opportunity for positive interaction, attention, stop and talk with him or her passing by, praise any indication of the resident's progress/improvement in behavior, the residents triggers for any subject that would cause him to see himself as a victim pain could be a punishment, repositioning (related to maladaptive feelings) encouragement could be seen as I'm not good enough, I'm a bad person the residents behavior is deescalated by non-accusation type statements.A review of the care plan date initiated 3/17/26 indicated Resident 1 has potential to be verbally aggressive to staff and fellow peers related to mental/emotional illness. Interventions: Administer medications as ordered, Monitor/ document for side effects and effectiveness, assess residents coping skills and support system, when resident becomes agitated intervene before agitation escalates get away from source of distress; engage calmly in conversation if response is aggressive staff to walk calmly away and approach later.A review of Resident 1's physician order summary from admission on [DATE] through his discharge 4/18/26, indicated Resident 1 was prescribed:-Buspirone (to treat Generalized Anxiety Disorder (GAD) and relieve short-term anxiety symptoms) HCI 10 milligrams (mg) one tablet three times a day related to anxiety manifested by anxiousness, started 2/24/26.-Bupropion (to treat depression) HCI extended release 300 mg one tablet by mouth one time a day related to depressive disorder manifested by sad statements, started 2/24/26.-Duloxetine (to treat depression and/or anxiety) HCI 30 mg one capsule one time a day related to depression manifested by pain, started 2/25/26.-Doxepin (to treat depression and/or anxiety) HCI 6 mg one tablet by mouth at bedtime related to depressive disorder manifested by sleeplessness, started 3/03/26, and discontinued 3/6/26. Increased with new order 3/6/26, Doxepin HCI 25 mg one tablet by mouth at bedtime related to depressive disorder, new order started 3/06/26.A review of the Medication Administration Record for February 2026 indicated monitoring of episodes anxiousness. There was a total of five episodes of behavior monitored to treat Generalized Anxiety Disorder (GAD) and relieve short-term anxiety symptoms for the month of February. No monitoring for episodes of depression, sleeplessness or sad statements.A review of the Medication Administration Record for March 2026 indicated monitoring of episodes anxiousness and sleeplessness. Records indicate 16 episodes of behaviors monitored to treat GAD and relieve short-term anxiety symptoms for the month of March. Record indicated a total of 126 episodes of sleeplessness for the month of March. No mention of monitoring for episodes of depression or sad statements.A review of Resident 1's Interdisciplinary Team (IDT, group of various medical staff that discuss resident plans of care) notes indicated no mention or documentation of review of Resident 1's behavioral symptoms, response to behavioral medications, or interventions and outcomes in the medical record.A review of Resident 1's order administration note dated 3/1/26 at 10:39 am, indicated Resident 1 continued to have mixed behaviors throughout shift, multiple staff attempted to provide care, Resident 1 frequently became frustrated with staff without clear reasoning, Resident 1 asked multiple staff to exit room but then would call that staff member back in. Resident 1 had delusions and frequently denied previous statements. In-house staff states that this is normal behaviors for this patient. Resident 1 refused offers for interventions frequently.A review of Resident 1's IDT note dated 3/4/26 at 7:48 am, Resident 1 was heard screaming help, help when staff walked in, no call light on. Stated I shit myself, yes I shit myself, are you going to change me. No referrals or changes to orders indicated in record.A review of Resident 1's behavioral note dated 3/17/26 at 7:48 am, Resident 1 was asked to change rooms yesterday and agreed after inappropriate behavior of stripping off his close and making comments that his dyeing roommate smells like PISS and that he was tired of that resident getting all the attention and we only cater to him This was all in front of the roommates family as they were all visiting.A review of Resident 1's social services note dated 3/27/26 at 6:40 pm, found resident mobile in wheel chair leaving social dining screaming at the top of his lungs, stating I'm sick of this shit No one does anything for me here I approached him , Identified myself while he was reading my badge and Resident 1 started hollering, your social services and you haven't done shit for me, get the F*** away from me. I replied, I've placed a call to the Ombudsman's office, and she will be here on Tuesday for your concerns. He told me to go to hell.A review of Resident 1's health status note dated 4/3/26 at 5:33 pm, Resident 1 called the police department and the ombudsman several times today leading to a call from Red Bluff change to local no proper names Police Department and a visit from the ombudsman (resident advocate). Resident 1 was asked what was wrong to which resident gave no real reason as to why he was having behaviors. Resident 1 then was asked again a few minutes later as he was notably verbally upset and he stated that he hated this facility and that he wished he was never sent here to which resident was reminded that he is his own responsible party and may discharge from facility at any time to which resident stated no that he was not leaving and wanted to stay. Resident 1 then stated that he cannot leave facility until he was able to stand or walk and that he was not going to do any of that unless he felt he wanted to and even admitted that he can stand and pivot with little difficulties and was doing so at home but if he began to stand and walk then he would potentially loose his disability benefits and began to say that if he was the type of person if he is unhappy or unsatisfied then he was going to make sure everyone was until they may be up for it. Resident 1 then began to complain about his roommate with no real reason as to why and then begins to complain of finances to which resident was reminded that nursing has nothing to do with insurance or finances to which he called nurse useless and became verbally aggressive yelling profanities at nursing staff. Resident 1 was also noted at time of meals will purposely demand to go into bathroom when trays need to be passed and staff needs to assist un-abled residents with meals and states that he loves to see everyone scramble over his needs needing to be met and stated that that's the way it should be always when it comes to his care.During a review of a health status note dated 4/10/26 at 6:54 am, Resident 1 has refused multiple times to go to the bathroom to be toileted. Resident 1 on every two-hour toileting program, explained to Resident 1 multiple times throughout night shift and this shift. He has a bedside commode (portable toilet) next to bed and the say sit to stand (device used to assist in standing up) was refused. Resident 1 finally agreed to use the sit and stand when assisting him from bed he stated, I can do this myself. Resident was transferred to bathroom via sit to stand.During a review of a health status note dated 4/10/26 at 5:30 pm, Resident 1 was noted to be putting fingers in his mouth and causing self to vomit. When asked why he was doing so he denied happenings even though it was brought to his attention that it was witnessed by several staff members. Resident 1 was educated on the risks from causing self to vomit to which resident stated that he understood the risks but continued denying doing and also continued with behavior.A review of a health status note dated 4/17/26 at 9:56 pm, Resident 1 being monitored due to behaviors, resident has been making sad statements that he wants to die. Resident 1 refused all medications from this LN, stating that taking his medication will make him sick. Resident 1 verbalized not feeling well but does not want help from this LN or MD here. Resident 1 verbalized not wanting to go to hospital either stating I don't trust them. During a concurrent interview and record review 6/9/26 at 10:00 am, Social Services Director (SSD) stated Resident 1 had no behavioral health diagnosis and was not prescribed behavioral health medications. Upon reviewing Resident 1's admission documentation SSD acknowledged that diagnoses of anxiety, personality disorder and depressive episodes as well as medications, were present at admission and stated that these diagnoses and medications had been overlooked during the admission review. SSD confirmed there were no records on mental health referrals and stated, I thought he only had personality disorder and missed the other diagnoses. SSD further stated our staff are not trained in psychiatry or psychological/mental health services.During a concurrent interview and record review on 6/9/26 at 11:20 am, the Director of Nursing (DON) stated Resident 1 declined mental health services and was unable to find documentation in the record of his refusal of mental health service. DON confirmed IDT did not evaluate Resident 1's behavioral symptoms or his response to behavioral medications. DON further explained Resident 1 was very difficult and confirmed they did not consider revising his care plan to include two staff present with all interactions with resident.

Based on interview, and record review, the facility's Administrator (ADMIN) failed to ensure resident rights were honored during care when:1. Four out of seven residents reported that Certified Nursing Assistant (CNA A) did not treat them with respect, did not consider their self-determination, and individuality when she provided care. 2. Nursing administrative staff did not provide oversight and provide education/feedback to CNA A after multiple resident complaints. Refer to F550.This resulted in a violation of four residents' rights to receive individualized respectful care and put all residents at risk for not receiving dignified care. Refer to F550.Findings:During a review of the facility Position Description for Administrator dated October 2003, indicated Position Summary The administrator is responsible for the day-to-day operations of the facility in accordance with the applicable policies and procedures, Corporate Integrity Agreement, current federal, state, and local standards, guidelines, and regulations that govern long-term care facilities. The administrator is responsible for developing and maintaining employee relations. Ensures that all resident's rights to fair and equitable treatment, self-determination, individuality, privacy, property and civil rights, including the right to file complaints, are well established and maintained at all times.Ensuring the coordination of the delivery of quality care and services.Ability to work harmoniously with and supervise other personnel and develop/maintain good personnel's relations and employee morale. Ability to interpret, communicate and implement policies, procedures, regulations, reports, etc. to personnel, residents, family members, visitors, and government agencies/personnel. Leads, plans, develops, organizes, implements, evaluates, and directs the facility's overall operations, programs and delivery of services on a daily basis. Identifies areas for improvement, develops effective plans, monitors and evaluates results and communicates to facility staff and regional team as necessary. During a review of the facility position description for Nursing Assistant State Certified/Licensed (CNA), dated October 2003, indicated Position Summary Responsible for providing residents with routine daily and restorative nursing care and services in accordance with the resident's assessment, care plan and as directed by supervisors. Ensures residents' needs are met while maintaining the highest degree of dignity.1.a. CNA A was rough when providing care to Resident 1.1.b. CNA A ignored Resident 2's request for her to be careful with her shoulder during care.1.c CNA A did not listen to or provide individualized care to Resident 3. 1.d. CNA A's behavior was not respectful during Resident 4's care.2. During an interview on 3/6/26 at 12:07 pm, with CNA B, CNA B stated that CNA A treated residents like Toddlers instead of adults. CNA B said, CNA A was not respectful. Resident 3 and Resident 4 informed me that CNA A was rude and abrupt. CNA B further stated that she directed Resident 3 to tell the ADMIN regarding her concern about CNA A and she also reported it to SS. CNA B acknowledged she had observed that CNA A being abrupt when taking off Resident 3's oxygen. CNA B stated she had also witnessed that CNA A being reported to administrative staff and nothing was done about CNA A.During an interview 3/6/26 at 12:32 pm, with CNA C, CNA C stated CNA A was a coworker they avoided because CNA A was reckless and displayed carelessness when caring for residents. CNA C stated residents preferred to have other staff care for them instead of CNA A. A review of CNA A's employee file indicated an annual performance report completed 11/18/25 by the Director of Staff Development (DSD, responsible for training and performance evaluations of CNA staff) indicated under areas needed improvement or development that she needed to take fewer extra hours.During an interview with the Director of Nursing (DON) on 3/6/26 at 1:30 pm, the DON stated that staff did not like CNA A. The DON reported being unaware of multiple resident allegations that CNA A failed to listen to residents and behaved in a disrespectful and unprofessional manner while providing care. The DON stated CNA A was aware that she worked quickly and was task oriented, which the DON acknowledged could result in resident needs being overlooked.During an interview on 4/10/26 at 12:18 pm, with Director of Staff Development (DSD, responsible for training and performance evaluations of CNA staff), the DSD stated she was unaware of the multiple resident and staff allegations involving CNA A. DSD stated that the SS or ADMIN took care of any CNA performance issues and that she had not been informed of concerns prior to the recent allegations but is now included. DSD explained she was responsible for completing the annual CNA performance reviews and confirmed there were no performance issues identified in the last one done for CNA A dated 11/8/25.During a phone interview on 4/21/26 at 10:29 am, with ADMIN, the ADMIN explained his role was to monitor CNAs performance and investigate resident complaints/issues. ADMIN stated if CNAs need counseling for a performance issue, he will provide the verbal instruction and expectations. ADMIN stated he usually does not document a corrective action counseling memo unless it is egregious (gross violation of standards intentional misconduct). Admin further stated in CNA A's situation was her lack of teamwork and performance issues which have been occurring over the past year. ADMIN stated he and DON sat down with CNA A a couple of times to speak about performance issues. ADMIN stated If counseling works then there are no formal written warnings. ADMIN stated he was aware of CNA A's work performance issues due to her being task focused and her lack of listening to residents' needs. Admin stated, I didn't consider it abuse I wondered if it was a personality conflict or communication issue. ADMIN stated, I do a lot of Director of Staff Development type work. in the facility. During a review of CNA A employee file included one counseling memo dated 2/9/26. The counseling indicated CNA A will benefit from a more person-centered approach with better communication during care. While task focused care may be efficient it is not necessarily effective. It can lead to fear and pain. CNA A will participate in a training program to improve the perception of the care she provides. CNA A resigned on 2/25/26.

Based on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA A) provided residents with dignity and respect during direct resident care for four of seven sampled residents (Resident 1, 2, 3 and 4) when:1. CNA A was rough when providing care to Resident 1.2. CNA A ignored Resident 2's verbal request to be careful with her shoulder during care.3. CNA A did not listen to or provide individualized care to Resident 3.4. CNA A's behavior during care was not respectful toward Resident 4.This failure resulted in a violation of four residents' rights to receive individualized respectful and dignified care.Findings:During a review of the facility position description for Nursing Assistant State Certified/Licensed (CNA), dated October 2003, the Position Summary indicated that the CNA is Responsible for providing residents with routine daily and restorative nursing care and services in accordance with the resident's assessment, care plan and as directed by supervisors. Ensures residents' needs are met while maintaining the highest degree of dignity.1. During a review of Resident 1's record, it indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (complete or near complete paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a stroke affecting left dominant side, muscle weakness and abnormalities of gait and mobility.A review of Resident 1's Minimum Data Set (MDS- a comprehensive assessment and screening tool), dated 2/15/26, the MDS indicated Resident 1 had a Brief Interview for Mental Status (BIMS, cognitive screening tool) and scored 13 (cognition intact). MDS also indicated that Resident 1 was dependent on staff for most mobility tasks, including changing position from sitting to lying, lying to sitting at the edge of the bed, and sit to stand transfers from chair to bed and bed to chair. Resident 1 was unable to walk more than 10 feet due to medical condition or safety concerns. During a review of a quarterly pain assessment record, dated 2/10/26, indicated Resident 1 had pain frequently in the last five days, and her pain level was 8 out of 10 (moderate to severe) and the pain happened three to four days in week. During an interview on 3/6/26 at 10:55 am, with Resident 1, Resident 1 stated CNA A was rough with my care particularly with my left shoulder causing a lot of pain. When asked on a pain scale from zero to ten how she would rate the pain Resident 1 stated a nine (severe pain). Resident 1 stated, it makes me feel like staff doesn't care.2. During a review of Resident 2's record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis following a stroke affecting left dominant side, abnormalities of gait and mobility and need for assistance with personal care.During a review of Resident 2's MDS, dated [DATE], indicated Resident 2 had a BIMS of 13 (cognition intact). MDS indicated, Resident 2 required supervision or touching assistance for sit to lying, and partial to moderate assistance for lying to sitting, sit to stand, and transfers between bed and chair. The MDS further indicated that the resident was able to walk 10 feet with supervision or touching assistance; however, walking 50 feet or 150 feet was not attempted due to medical condition or safety concerns.During a review of Resident 2's admission pain assessment, dated 1/12/26, Resident 2 had occasional pain in the last 5 days. Resident 2 indicated her pain was at a level five (moderate pain) which happened three to four days a week. During a review of Resident 2's Interdisciplinary Team (IDT, a group of healthcare disciplines that develop resident plans of care) meeting note, dated 1/22/26 at 1:51 pm, by the Administrator (ADMIN), indicated that Resident 2 had come to the ADMIN's office to report to that CNA A opened the bathroom window and left her on the toilet. CNA A then informed Resident 2 in so many words to pull her own pant up. IDT note indicated ADMIN let Resident 2 know the situation was taken care of.During an interview on 3/06/26 at 11:18 am, with Resident 2, Resident 2 stated she doesn't have an issue now with CNA A since she's no longer employed at the facility. Resident 2 stated CNA A had come into the room to get Resident 2 out of bed. Resident 2 stated she informed CNA A My right shoulder has arthritis, and it hurts but CNA A Ignored her. Resident 2 stated, It hurt significantly. Resident 2 stated her roommate (Resident 3) requested a box of crackers out of her bedside drawer. CNA A walked over to the roommate's area looked in the drawer and informed Resident 3 that there were no crackers in the drawer. Resident 2 stated there were crackers in the drawer. Resident 2 stated, It made me mad. Resident 2 stated the first time she informed ADMIN about CNA A, he explained she would no longer have CNA A come back into her room. Resident 2 stated after that CNA A would walk by her room and Stare at me. Resident 2 stated, It made me feel like she would continue to abuse me. Resident 2 stated I didn't feel safe with CNA A working with me but now that she is gone, I am happy. Resident 2 stated CNA A came into her room to plug something in and Resident 2 stated to CNA A, You aren't supposed to be in this room and informed Social Services (SS), that she wanted something done with CNA A. Resident 2 stated SS asked her if CNA A apologized to her, Would that work? Resident 2 stated No. Resident 2 further stated that ADMIN listened to the concerns and said CNA A should have been fired. Resident 2 stated, I feel safe now that the CNA A is no longer here.3. During a review of Resident 3's admission record, indicated Resident 3 was admitted to the facility on [DATE], with diagnoses which included muscle weakness, paroxysmal atrial fibrillation (on and off chaotic heart beats instead of steady heart beats) and high blood pressure.During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had BIMS, of 10 (moderately impaired). MDS indicated that Resident 3 required partial to moderate assistance for sit to lying and lying to sitting transfers, and substantial to maximum assistance for sit to stand transfers, including transfers from chair to bed and bed to chair. The MDS further indicated that Resident 3 could not walk more than 10 feet due to the resident's medical condition or isafety concerns. During an interview on 3/06/26 at 11:33 am, with Resident 3, Resident 3 stated CNA A Didn't have enough patience when explaining things and it made her feel like She would just cut her off if I said anything. Resident 3 stated it made her feel Angry, but she didn't want to push it. Resident 3 further stated that she heard CNA A raise her voice with other residents'. Resident 3 stated she hadn't seen CNA A recently and she was told CNA A was no longer at the facility. Resident 3 stated I'm glad I'll never see her walk through the doors again.4. During a review of Resident 4's admission record, indicated that Resident 4 was admitted on [DATE] to the facility, with diagnoses which included hemiplegia and hemiparesis, stroke affecting left dominant side and high blood pressure.During a review of Resident 4's MDS dated [DATE], indicated Resident 4 had BIMS of 13 (cognition intact). The MDS indicated that Resident 4 required partial to moderate assistance for sit to lying, substantial to maximal assistance for lying to sitting on the side of the bed, and was dependent for sit to stand transfers, including transfers between chair and bed. The MDS further indicated that walking 10 feet, 50 feet, and 150 feet, Resident 4 required supervision or touching assistance During an interview on 3/6/26 at 10:30 am, with Resident 4, Resident 4 stated CNA A Horsed around a lot. Resident 4 stated at first CNA A was Nasty to her. Resident 4 stated CNA A wanted to Flirt with male staff instead of paying attention to residents. When asked about CNA A and the flirting with staff, Resident 4 stated CNA A would Giggle a lot and it would get on her nerves hearing the CNAs horsing around and giggling. Resident 4 stated, It didn't feel like it was respectful for CNA A to horse around and flirt with staff when she was paid to take care of residents.During an interview on 3/6/26 at 12:07 pm, with CNA B, CNA B stated that CNA A treated residents like Toddlers instead of adults. CNA B said, CNA A was not respectful. Resident 3 and Resident 4 informed me that CNA A was rude and abrupt. CNA B further stated that she directed Resident 3 to tell the ADMIN regarding her concern about CNA A and she also reported it to SS. CNA B acknowledged she had observed that CNA A being abrupt when taking off Resident 3's oxygen. CNA B stated she had also witnessed that CNA A being reported to administrative staff and nothing was done about CNA A.During an interview 3/6/26 at 12:32 pm, with CNA C, CNA C stated CNA A was a coworker they avoided because CNA A was reckless and displayed carelessness when caring for residents. CNA C stated residents preferred to have other staff care for them instead of CNA A. During an interview with the Director of Nursing (DON) on 3/6/26 at 1:30 pm, the DON stated that staff did not like CNA A. The DON reported being unaware of multiple resident allegations that CNA A failed to listen to residents and behaved in a disrespectful and unprofessional manner while providing care. The DON stated CNA A was aware that she worked quickly and was task oriented, which the DON acknowledged could result in resident needs being overlooked.During an interview on 4/10/26 at 10:10 am, with CNA A, CNA A stated she was aware that Resident 3 had reported feeling uncomfortable with her care. CNA A stated she assisted Resident 3 to the restroom and opened a window after a bowel movement, and that Resident 3 did not indicate discomfort or embarrassment after other residents commented on the odor. CNA A stated that following the incident, Resident 3 accepted assistance once but declined further care. CNA A reported being instructed to monitor Resident 3's facial expressions and limit unnecessary interaction with Resident 3. CNA A acknowledged that additional residents had expressed concerns about her care, and stated she resigned from the facility on 2/25/26 During an interview on 4/10/26 at 12:18 pm, with Director of Staff Development (DSD, responsible for training and performance evaluations of CNA staff), the DSD stated she was unaware of the multiple resident and staff allegations involving CNA A. DSD stated that the SS or ADMIN took care of any CNA performance issues and that she had not been informed of concerns prior to the recent allegations but is now included. DSD explained she was responsible for completing the annual CNA performance reviews and confirmed there were no performance issues identified in the last one done for CNA A dated 11/8/25.

Based on observation, interview, and policy review, the facility failed to maintain the facility in a clean, safe and comfortable home-like environment when:1. The sliding glass door in room [ROOM NUMBER] did not lock properly.2. room [ROOM NUMBER] had buckled, worn brown flooring that was on the right side of the sliding glass door, which made this door hard to slide.3. There was a hole in the bathroom door in room [ROOM NUMBER].4. The bathrooms on the south hall, rooms 14 through 25 needed repair and paint.5. The sliding glass doors were hard to open and slide and unclean in 10 resident rooms on the south hall.6. The nurses' station had chipped and worn areas around the sink and the molding and flooring.7. The Brio water fountain in the front lobby had a stained, unclean drain for the resident and community use. This failure had the potential to negatively affect client's health, safety, and comfort and the potential to spread other bacteria in the facility to other residents, staff, visitors, and the community. Findings:1. During a review of the facility's policy and procedure (P&P) titled. Maintenance Service, revised 12/2009, the P&P indicated the maintenance department shall be provided to all areas of the building, grounds, and equipment. The Maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.During an observation on 1/20/26 at 9:19 am, the sliding glass door is room [ROOM NUMBER] was not locked properly and the lock needed to be repaired or replaced.During an interview on 1/20/26 at 9:45 am, the Administrator (Admin) confirmed the sliding glass door in room [ROOM NUMBER] did not lock properly. Admin stated, We will get this fixed immediately. I confirm the lock on room [ROOM NUMBER]'s door does not lock properly. During an interview on 1/20/26 at 9:50 am, the Maintenance Director (Main) confirmed the lock on room [ROOM NUMBER] did not work properly and stated, I did not know about this, or I would have already fixed this, I will get this done as soon as possible.2. During an observation on 1/20/26 at 9:20 am, there was a buckling, raised, weak area of the brown flooring in room [ROOM NUMBER] beside the sliding glass door, making the sliding glass door hard to open.During an interview on 1/21/26 at 2:30 pm, with the Admin, the Admin confirmed there was an area in the flooring that needed repair, and blue tape had already been placed over it for the maintenance department to repair. 3. During an observation on 1/20/26 at 9:24 am, there was a hole in the inside portion of the bathroom door of room [ROOM NUMBER].During an interview on 1/21/26 at 2:35 pm, with the Admin, the Admin confirmed the hole in the bathroom door would be repaired or replaced. 4. During an observation on 1/20/26 from 9:21 am to 9:37 am, the shared residents' bathrooms in rooms 14, 15, 17, 19 and room [ROOM NUMBER] had holes, chipped paint, chipped molding, and white paint marks on the brown flooring. 5. During an observation on 1/20/26 from 8:20 am to 9:15 am, the sliding glass doors (rooms 14, 15, 16, 17, 18, 19, 20, 21, 22, and room [ROOM NUMBER]) tracks had cumulative dust and debris and were difficult to slide properly.During an interview on 1/20/26 at 2:30 pm, with the Admin, the Admin confirmed all the sliding glass doors on the south hall (rooms 14 through 23) tracks were not clean with cumulative dust and dirt and were hard to slide. The Admin confirmed the bathrooms in rooms 14 through 25 needed paint and minor repairs, one bathroom door had a hole in it.During an interview on 1/21/26 with the Director of Nursing (DON), the DON confirmed the bathrooms on the south hall including rooms 14 through 25 needed paint and minor repairs to the molding, and the flooring around the pipes. The DON also confirmed room [ROOM NUMBER] had a hole in the bathroom door, and room [ROOM NUMBER] had flooring that needed repair. DON stated, I do confirm all the sliding glass doors on this hall need to be cleaned at the sliders, and all the locks should work properly for safety.During an interview on 1/22/26 at 9:15 am, with the Admin, the Admin stated, We need a new check list to include the sliding glass doors and tracks for the staff to follow to make sure this is done consistently.During an interview on 1/22/26 at 9:37 am, with the Environmental Supervisor (EVS), the EVS stated, I will change the check list and logs to add all the items that need to be cleaned regularly and for the deep cleaning to make sure these doors are included in the routine cleaning. I confirm the staff was not cleaning the door tracks because it is not on their list of duties. 6. During a concurrent observation and interview on 1/20/26 at 11:16 am, with Registered Nurse (RN) M, RN M confirmed the nurse's station sink area was unclean, with cumulative dust and debris. The wood molding on the left side of the station door was chipped and needed repair and paint. RN stated, I confirm this station needs some work, the flooring is also worn from the chairs we use in here.7. During a review of the facility's policy and procedure (P&P) revised 8/2010, titled, Cleaning and Disinfection of Environment, revised 8/2010, the P&P indicated environmental surfaces will be cleaned and disinfected according to current Center of Disease Control (CDC) recommendations for disinfection of healthcare facilities. Non-critical items (items that come in contact with intact skin but not mucous membranes). Non-critical environmental surfaces include bedrails, some food utensils, bedside tables, furniture and floors. Housekeeping surfaces (floors and tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. Environmental surfaces will be disinfected (or cleaned) on a regular basis, example three times per week) and when surfaces are visibly soiled.During an observation on 1/22/26 at 11:36 am, the Brio water fountain in the front lobby had a stained, unclean drain to this water fountain used by residents and the community.During an interview on 1/22/26 at 2:45 pm, with the Main, Main confirmed the water fountain had a stained water drain and was used by residents and the community. Main stated, We have hard water, but the filters are changed as required, I have the logs and the machine's light will come on when it needs to be changed. I will remove the drain and scrub it. There is no rust, there is a red button on the right side of the drain.

Based on interview, and record review, the facility failed to ensure that seven of eight sampled residents knew the correct procedure to file a grievance with the facility (Resident 1, Resident 19, Resident 22, Resident 23, Resident 25, Resident 39, Resident 45), three of the eight sampled residents were not informed of the findings of the investigations or any corrective actions that were taken for their grievances, (Resident 1, Resident 19, Resident 22), and three of the eight sampled residents stated that they were fearful of retaliation if they filed a grievance (Resident 22, Resident 39, and resident 45).This deficient practice had the potential for residents to be unaware or confused about the process for filing grievances, for grievances to be left uninvestigated or corrected, or residents not being informed of the actions taken for their grievances and for residents to have a concern of retaliation if they filed a grievance or complaint. During a record review of facility policy titled Investigating Grievances/Complaints dated 2001 MED-PASS indicated, Upon the receipt of a grievance and complaint report, [grievance officer] will begin an investigation into the allegations. The department director of an involved employee will be notified of the nature of the complaint and that an investigation is underway. The investigation and report will include, as each may apply: The date and time of the alleged incident; the circumstances surrounding the alleged incident; the location of the alleged incident; the names of any witnesses and their account of the alleged incident; the resident's account of the alleged incident; the employee's account of the alleged incident; accounts of any other individuals involved; and recommendations for corrective action. Facility policy further indicated The resident, or person acting in behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended, within _____ working days of the filing of the grievance or complaint. Facility policy also indicated A copy of the 'Resident Grievance/Complaint Investigation Report Form' must be attached to the 'Resident Grievance/Complaint Form' and filed in the business office. Facility policy indicated Copies of all reports must be signed and will be made available to the resident or person acting in behalf of the resident. Resident 1 had a Brief Interview for Mental Status score of 15 (BIMS- a screening tool used to assist with identifying a residents current ability to think and reason. The total possible BIMS score ranges from 00-15; 13-15 is cognitively intact, 08-12 is moderately impaired, 00-07 is severely impaired).During a record review of Resident 1's admission record, she was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (life-threatening event where lungs rapidly fail to oxygenate blood or remove carbon dioxide, requiring emergency care), chronic obstructive pulmonary disease (COPD - a condition involving constriction of the airways and difficulty or discomfort in breathing), pneumonia (a lung infection causing the air sacs to fill with fluid or pus, leading to inflammation and making breathing difficult), and dependence on supplemental oxygen (use of oxygen provided by an oxygen tank supplied by a tube in the nostrils). During a record review of Resident 19's admission record, she was admitted to the facility on [DATE] with diagnoses that included unspecified dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change), nutritional deficiency (not getting enough calories), and glaucoma (eye disease that damages the optic nerve leading to vision loss and potential blindness). Resident 19 had a BIMS score of 05.During a record review of Resident 22's admission record, he was admitted to the facility on [DATE] with diagnoses that included congestive heart failure (a chronic condition where the heart muscle weakens and cannot pump enough oxygen-rich blood to meet the body's needs, causing blood and fluid to back up in the lungs, legs, and other parts of the body), myocardial infarction (heart attack), and abnormalities of gait and mobility (changes in normal walking patterns). Resident 22 had a BIMS score of 14.During a record review of Resident 23's admission record, she was admitted to the facility on [DATE] with diagnoses that included osteoarthritis of the right and left knee (degenerative joint disease where the protective cartilage cushioning the ends of bones wears down over time), low back pain, and localized edema (swelling of a specific area of the body). Resident 23 had a BIMS score of 13.During a record review of Resident 25's admission record, she was admitted to the facility on [DATE] with diagnoses that included muscle weakness, seizures (a temporary disruption of normal brain activity caused by sudden, excessive electrical signals, leading to changes in awareness, behavior, sensation, or muscle control), and hyperlipidemia (high concentration of fats or lipids in the blood). Resident 25 had a BIMS score of 11.During a record review of Resident 39's admission record, she was admitted to the facility on [DATE] with diagnoses that included COPD, primary focal hyperhidrosis, and atrial fibrillation (a rapid, irregular heartbeat caused by chaotic electrical signals in the heart's upper chambers). Resident 39 had a BIMS score of 13.During a record review of Resident 45's admission record, she was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, dysphagia (difficulty swallowing), and difficulty in walking. Resident 45 had a BIMS score of 08.During an interview on 1/21/26 at 10:00 am, Resident 1 stated she went to the Administrator's office (Admin) and told him her concerns that pertained to Certified Nursing Assistant (CNA) H who was rough around the edges with her. Resident 1 stated she did not receive any feedback from Admin on how her concern was handled. Resident 1 stated she did not know how to file a grievance or where the forms were.During an interview on 1/21/26 at 10:00 am, Resident 19 stated CNA H bothered her and made her feel uncomfortable. Resident 19 stated she told Admin I his office, but did not hear back from him. Resident 19 stated she did not know how to file a grievance or where the forms were.During an interview on 1/21/26 at 10:00 am, Resident 22 stated the Director of Nursing (DON) was not kind, and he had a fear of retaliation from DON and CNA H if he mentioned his concerns to Admin. Resident 22 named CNA H by name to Admin but stated I never knew if he did anything about it. Resident 22 stated complaint process was to go to Admin's office or Social Service/Admission's (SS/Admit) office to verbally express any complaints or concerns. Resident 22 stated he did not know how to file a grievance or where the forms were.During an interview on 1/21/26 at 10:00 am, Resident 23 stated she asked CNA H for help with pulling her brief (adult diaper) past her knees when she sat on her toilet. Resident 23 stated her bathroom window was open. Resident 23 stated CNA H told her You need to do it yourself. Resident 23 stated it made her feel like she was alone and could not count on staff to help her when she needed help. Resident 23 stated she did not know how to file a grievance or where the forms were.During an interview on 1/21/26 at 10:00 am, Resident 25 stated she told Admin about her concerns about CNA H. Resident 25 stated she went to Admin's office to tell him CNA H was not nice to her and thought this was the complaint process. Resident 25 stated she did not know how to file a grievance or where the forms were.During an interview on 1/21/26 at 10:00 am, Resident 39 stated she was left on her toilet, cold, with her brief down below her knees because it was difficult to pull up past her knees. Resident 39 stated this made her feel humiliated. Resident 39 stated she told Admin, but she felt scared to push it any further because of fear of retaliation by CNA H and staff. Resident 39 stated she did not know how to file a grievance or where the forms were.During an interview on 1/21/26 at 10:00 am, Resident 45 stated she had concerns and complaints she would like to file with the facility but had a fear of retaliation from staff. Resident 45 stated she did not know how to file her concerns or complaints about the facility. Resident 45 stated she did not know how to file a grievance or where the forms were.During an interview on 1/21/26 at 11:41 am, Admin confirmed the facility did not have grievance forms available for the residents to access when they wanted to. Admin stated he developed his own complaint process for residents where they would come to his office, verbalize their complaint/concern, and if he felt their complaint/concern was a grievance, he would help them fill out a grievance form, or he would handle it himself. Admin confirmed there was no tracking of residents' complaints/concerns, interventions, or effectiveness of interventions. Admin confirmed he should have the grievance forms available for residents in case some wanted to remain anonymous. Admin stated the grievance form was difficult for residents to fill out, and this was the reason he put the grievance forms in SS/Admit's office, and instead, used one line on his personal Daily Morning Meeting form (a form Admin created for his own personal use to keep track of his work) called Customer Service. Admin stated if a resident was unhappy, he would draw a mad face. Admin stated he would write down room numbers of residents on the Customer Service line to recall what he needed to follow up with, but admitted sometimes, he would forget what they needed. During an interview on 1/21/26 at 1:21 pm, SS/Admit stated she had a grievance binder in her office. SS/Admit confirmed the last grievance filed by a resident at the facility was on 7/22/24. SS/Admit stated this was because everyone's happy. SS/Admit stated she was not sure who the facility grievance officer was. SS/Admit stated she was not sure why residents used to give her grievances, but not anymore. SS/Admit stated she was unaware that residents went to Admin to complain and that he listed those complaints on his own personal form. SS/Admit confirmed residents deserved the right to file grievances and that the fear of retaliation by staff could be a fear of some of them.During an interview on 1/21/26 at 1:33 pm, DON confirmed SS/Admit was the facility grievance officer. DON confirmed residents went to Admin and SS/Admit and verbalized their concerns and complaints, but the investigations of those concerns or complaints were not documented or tracked. DON stated she was unaware Admin had his own personal form where he listed resident concerns. DON confirmed residents have the right to file a grievance. DON stated Admin should not pre-determine if a resident concern or complaint warranted a grievance. DON confirmed it was not the facility's place to be involved in whether a resident filed a grievance, or not. During an interview on 1/21/26 at 3:00 pm, Admin stated SS/Admit defined a grievance as something of a resident's was stolen or missing. Admin confirmed a grievance reason can be anything a resident wanted it to be. Admin confirmed facility needed to implement and allow access to the grievance process for residents. Admin confirmed it was a resident's right to file a grievance and have that grievance investigated and followed up on by facility. Admin confirmed facility had not followed its grievance policy and should have.

Based on interviews, and record reviews, the facility failed to report allegations of mistreatment, made by five of eight sampled residents (Resident 1, Resident 19, Resident 22, Resident 25, and Resident 39) to the appropriate local, state, and federal agencies nor were the residents informed of the progress of an investigation.This failure caused resident complaints/concerns of mistreatment by staff to go unreported with the potential of continued mistreatment, physical and/or psychosocial harm to residents. During a record review of facility policy titled Abuse Investigation and Reporting revision date 07/2017 indicated, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state and federal (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Facility policy also indicated, The Administrator (Admin) will keep the resident and his/her representative informed of the progress of the investigation, and the Admin will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. Facility policy further indicated, The Admin will ensure that any further potential abuse, neglect, exploitation or mistreatment is prevented.During a record review of Resident 1's admission record, she was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (life-threatening event where lungs rapidly fail to oxygenate blood or remove carbon dioxide, requiring emergency care), chronic obstructive pulmonary disease (COPD - a condition involving constriction of the airways and difficulty or discomfort in breathing), pneumonia (a lung infection causing the air sacs to fill with fluid or pus, leading to inflammation and making breathing difficult), and dependence on supplemental oxygen (use of oxygen provided by an oxygen tank supplied by a tube in the nostrils). Resident 1 had a Brief Interview for Mental Status score of 15 (BIMS- a screening tool used to assist with identifying a residents current ability to think and reason. The total possible BIMS score ranges from 00-15; 13-15 is cognitively intact, 08-12 is moderately impaired, 00-07 is severely impaired).During a record review of Resident 19's admission record, she was admitted to the facility on [DATE] with diagnoses that included unspecified dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change), nutritional deficiency (not getting enough calories), and glaucoma (eye disease that damages the optic nerve leading to vision loss and potential blindness). Resident 19 had BIMS score 05.During a record review of Resident 22's admission record, he was admitted to the facility on [DATE] with diagnoses that included congestive heart failure (a chronic condition where the heart muscle weakens and cannot pump enough oxygen-rich blood to meet the body's needs, causing blood and fluid to back up in the lungs, legs, and other parts of the body), myocardial infarction (heart attack), and abnormalities of gait and mobility (changes in normal walking patterns). Resident 22 had a BIMS score of 14.During a record review of Resident 23's admission record, she was admitted to the facility on [DATE] with diagnoses that included osteoarthritis of the right and left knee (degenerative joint disease where the protective cartilage cushioning the ends of bones wears down over time), low back pain, and localized edema (swelling of a specific area of the body). Resident 23 had a BIMS score of 13.During a record review of Resident 25's admission record, she was admitted to the facility on [DATE] with diagnoses that included muscle weakness, seizures (a temporary disruption of normal brain activity caused by sudden, excessive electrical signals, leading to changes in awareness, behavior, sensation, or muscle control), and hyperlipidemia (high concentration of fats or lipids in the blood). Resident 25 had a BIMS score of 11.During a record review of Resident 39's admission record, she was admitted to the facility on [DATE] with diagnoses that included COPD, primary focal hyperhidrosis, and atrial fibrillation (a rapid, irregular heartbeat caused by chaotic electrical signals in the heart's upper chambers). Resident 39 had a BIMS score of 13.During a record review of Resident 45's admission record, she was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, dysphagia (difficulty swallowing), and difficulty in walking. Resident 45 had a BIMS score of 08.During an interview on 1/21/26 at 10:00 am, Resident 1 stated she went to Admin's and told him her concerns that pertained to Certified Nursing Assistant (CNA) H who was rough around the edges with her and made her feel uneasy. Resident 1 stated CNA H did not speak nice to her or help her when Resident 1 requested help. Resident 1 stated she did not receive any feedback from Admin on how her concern was handled. During an interview on 1/21/26 at 10:00 am, Resident 19 stated CNA H bothered her and made her feel uncomfortable. Resident 19 stated she told Admin in his office but did not hear back from him.During an interview on 1/21/26 at 10:00 am, Resident 22 stated the Director of Nursing (DON) was not kind, and he had a fear of retaliation from DON and CNA H if he mentioned his concerns to Admin. Resident 22 named CNA H by name to Admin but stated I never knew if he did anything about it. Resident 22 stated complaint process was to go to Admin's office or Social Service/Admission's (SS/Admit) office to verbally express any complaints or concerns. During an interview on 1/21/26 at 10:00 am, Resident 23 stated she asked CNA H for help with pulling her brief (adult diaper) past her knees when she sat on her toilet. Resident 23 stated her bathroom window was open. Resident 23 stated CNA H told her You need to do it yourself. Resident 23 stated it made her feel like she was alone and could not count on staff to help her when she needed help. During an interview on 1/21/26 at 10:00 am, Resident 25 stated she told Admin about her concerns about CNA H. Resident 25 stated she went to Admin's office to tell him CNA H was not nice to her and thought this was the complaint process. During an interview on 1/21/26 at 10:00 am, Resident 39 stated she was left on her toilet, cold, with her brief down below her knees because it was difficult to pull up past her knees. Resident 39 stated this made her feel humiliated. Resident 39 stated she told Admin, but she felt scared to push it any further because of fear of retaliation by CNA H and staff. During an interview on 1/21/26 at 10:00 am, Resident 45 stated she had concerns and complaints she would like to file with the facility but had a fear of retaliation from staff, especially CNA H. During an interview on 1/21/26 at 11:10 am, Minimum Data Set/Director of Staff Development (MDS/DSD) stated CNA H sometimes yells down the hallway instead of using the walkie-talkie (a small portable radio set for receiving and sending messages) we have for staff. MDS/DSD confirmed she could understand how residents felt uneasy around CNA H. MDS/DSD stated she had never given CNA H any disciplinary actions because Admin and DON oversaw disciplinary actions for CNAs.During an interview on 1/21/26 at 11:41 am, Admin stated there were around four complaints a year in regard to CNA H's treatment of residents. Admin stated residents complained about how she spoke to them and how it made them feel disrespected. Admin stated residents also complained that she did not help them when they requested. Admin stated he did not enforce written disciplinary action with CNA H because he felt she was coachable. Admin confirmed a staff member was not coachable if she required four verbal disciplinary counseling sessions a year. Admin confirmed there was no tracking of residents' complaints/concerns, interventions, or effectiveness of interventions. Admin stated the grievance form was difficult for residents to fill out, and this was the reason he put the grievance forms in Social Service's (SS) office, and instead, used one line on his personal Daily Morning Meeting form (a form Admin created for his own personal use to keep track of his work) called Customer Service. Admin stated if a resident was unhappy, he would draw a mad face. Admin stated he would write down room numbers of residents on the Customer Service line to recall what he needed to follow up with, but admitted sometimes, he would forget what they needed. Admin confirmed residents came to his office all the time to verbalize their complaints/concerns about staff.During an interview on 1/22/26 at 11:35 am, Licensed Nurse (LN) K stated he spoke to CNA H about her communication with residents. LN K stated residents have complained that she was verbally aggressive towards them. LN K stated he spoke to DON in regard to CNA H's behavior a couple of times.During an interview on 1/22/26 at 12:01 pm, CNA A stated she had received resident complaints in regard to how CNA H treated residents. CNA A stated CNA H was verbally aggressive and sometimes, physically rough with residents. CNA A stated residents told her they did not want CNA H to take care of them anymore. CNA A stated she told LN J about resident complaints in regard to CNA H. CNA A stated she felt facility could do a better job to protect the residents from being mistreated by staff. CNA A stated CNA H told residents You can do it. Do it yourself.During an interview on 1/22/26 at 11:57 am, LN J confirmed she had received complaints from residents in regard to how CNA H treated them. LN J stated the complaints regarded how CNA H was verbally aggressive and residents feeling mistreated. LN J stated CNA H told residents what to do. LN J confirmed residents have the right to refuse care and the right to refuse to do something. LN J stated she understood how a resident would likely refuse care if they felt like they were being mistreated by staff. LN J stated she told DON and Admin about resident complaints in regard to CNA H, and was told by both they would talk to them.During an interview on 1/22/26 at 12:06 pm, Assistant Director of Nursing (ADON) stated CNA H was verbally aggressive with residents and that it made the residents feel uncomfortable and not want to complete activities or get out of bed. ADON stated CNA H was blunt in how she communicates with residents.During an interview on 1/22/26 at 2:05 pm, Admin stated he felt CNA H's behaviors towards the residents were not abuse. Admin confirmed he did not report resident concerns and implement facility abuse investigation process because determined the resident complaints did not constitute abuse. Admin stated his definition of abuse meant cuts, bruises, scars, or injuries. Admin stated abuse is determined if SS/Admit, DON, or himself says it is. Admin stated if there was a suspicion of abuse, he initiated an investigation, but was not going to fill out an SOC 341 for every little thing (a mandatory California Department of Social Services form used by those legally required to report suspected child/elder abuse or neglect to authorities, to report suspected physical abuse, neglect, financial abuse, isolation, or abandonment of elders (age 65+) or dependent adults (ages 18-64). It must be submitted within two working days of a verbal report). Admin stated he did not feel CNA H was uncoachable because the DON told him that CNA H was a good aide. Admin stated his definition of a good aide was someone who completed their tasks, was not late, and smiled in interviews. Admin stated, I can identify with the residents and how they feel about [CNA H] because I once felt that way, but if I go and talk to them, and explain 'Hey, this is just how she is,' then they usually go 'Okay,' and it ends up being fine. During an interview on 1/23/26 at 8:32 am, SS/Admit stated abuse to her meant fiduciary (financial), physical, mental, sexual, and emotional distress. SS/Admit stated suspected abuse was investigated immediately. SS/Admit stated Admin decided if a resident's complaint/concern in regard to staff to resident treatment constituted abuse. SS/Admit stated Admin decided if an SOC 341 was filled out. SS/Admit confirmed facility did not follow its reporting policy and should have.During an interview on 1/23/26 at 9:32 am, DON stated abuse to her meant sexual, verbal, fiduciary, physical, and neglect. DON confirmed abuse should be determined by how staff treatment towards a resident made that resident feel. DON stated abuse allegations were handled by herself, SS/Admit, and Admin. DON confirmed SOC 341 was only filled out if she or Admin felt it needed to be. DON stated CNA H had been verbally counseled in regard to her treatment of residents and how her treatment made them feel. DON confirmed residents had complained about CNA H not being nice to them. DON stated she was unaware that Admin had verbally counseled CNA H multiple times. DON confirmed facility did not follow its reporting policy and should have.

Based on observation, interview, and record review, the facility failed to ensure oxygen equipment was stored and dated per policy for two out of three sampled residents (Resident 1 and Resident 31) when the oxygen tubing for Resident 1 and Resident 31 was lying on their wheelchairs, uncovered and not dated.This failure had the potential to contaminate the oxygen tubing and cause an infection to the residents which could spread to other residents, staff, and visitors. Findings:During a review of the facility's policy and procedure (P&P) titled, Oxygen Storage and Use, dated 10/22/2010, the P&P indicated, to provide safe storage and use of oxygen. The oxygen cannula, mask etc. shall be changed when soiled. The cannula, mask, etc. shall be stored in a plastic bag when not in use. Logging and changing of oxygen shall be completed per facility policy.During a review of Resident 1's admission Record, dated 11/3/25, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure (severe shortness of breath, rapid breathing that can be an emergency lasting short term or ongoing persistence of difficulty breathing), chronic pulmonary obstructive disease (COPD, a progressive lung disease that causes shortness of breath), pneumonia (common, often serious infection of one or both lungs from bacteria or a virus that inflames the air sacs), dependence of supplemental oxygen (no longer able to get enough air into the lungs for normal breathing), heart disease, diabetes (too much sugar in the blood), and neuralgia (painful nerve pain. During a review of Resident 1's most recent Minimum Data Set, (MDS, a resident assessment tool) for Resident 1 dated 11/13/25, the MDS indicated that Resident 1 had a brief interview for mental status (BIMS) score of 15 out of 15, which indicated Resident 1 had the mental capacity to make medical decisions.During a review of Resident 1''s Active Orders (AO), dated 12/22/25, the AO indicated Resident 1 was ordered Oxygen 3 liters (l) via nasal cannula (n/c, through the nose) day and night for shortness of breath and/or to maintain oxygen levels greater or equal to 90%.A review of Resident 1's Active Orders (AO), dated 12/22/25, the AO indicated indicated Resident 1 was ordered change oxygen and or nebulizer tubing every seven days and (date and label all components) every week, every Tuesday.During an observation on 1/20/26 at 8:55 am, Resident 1's oxygen tubing was lying on the back of her wheelchair, not covered or dated.During a review of Resident 31's admission Record, dated 6/4/18, indicated Resident 31 was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure, COPD, diabetes, malaise (general fatigue, feeling unwell, lacking energy), neuralgia, depressive episodes (recurrent periods of sadness and loss of interest) and chronic pain (persistent pain lasting over 3 months).During a review of Resident 31's most recent Minimum Data Set, (MDS, a resident assessment tool) for Resident 31 dated 11/29/25, the MDS indicated that Resident 31 had a brief interview for mental status (BIMS) score of 10 out of 15, which indicated Resident 31 had a moderate cognitive (ability to think, reason, and problem solve) impairment. During a review of Resident 31's Active Orders (AO), dated 12/22/25, the AO indicated Resident 31 was ordered Oxygen 2 l via (n/c) for shortness of breath and/or to maintain oxygen levels greater or equal to 90% at bedtime while sleeping.A review of Resident 31's Active Orders (AO), dated 12/22/25, the AO indicated indicated Resident 31 was ordered Change oxygen and or nebulizer tubing every seven days and (date and label all components) every week, every Tuesday.During an observation on 1/20/26 at 8:57 am, Resident 31's oxygen tubing was lying on her wheelchair inside her red shoes, not covered or dated.During an interview on 1/21/26 at 8:22 am, with Registered Nurse (RN) M and Licensed Nurse (LN) J, RN M and LN J confirmed oxygen tubing not covered can cause an infection. RN M stated, We added oxygen tubing storage to the orders for [Resident 1] and [Resident 31] and moving forward it will be part of the admission process for all nurses to document in the record. We will add this order for oxygen storage when any resident is admitted or ordered oxygen. We are going to use the clear plastic bags for storage on the wheelchairs. The nurses will date and change as needed. During an interview on 1/21/26 at 9:00 am, with the Director of Nursing (DON), DON confirmed the oxygen tubing needed to be changed for Resident 1 and Resident 31 weekly and as needed and stored in a plastic bag with the date. The DON confirmed not following theses orders could cause an infection for Resident 1 and Resident 31 for not keeping the oxygen tubing stored in a clean plastic bag.

Based on interview and record review, the facility failed to complete annual performance evaluations for four of five sampled Certified Nursing Assistants (CNAs - CNA C, F, G and H).This failure had the potential for direct care staff not to provide quality of care and meet the needs of the residents.During a record review of facility policy titled Performance Evaluations dated 2001 MED-PASS indicated, A performance evaluation will be completed on each employee at the conclusion of his/her 90-day probationary period, and at least annually, thereafter. The performance evaluation meeting will occur at the same time as the employee's compensation review. Facility policy further indicated Performance evaluations may be used in determining employee promotions, shift/position transfers, demotions, terminations, wage increased, etc., and to improve the quality of the employee's work performance.During a record review of CNA C's employment file, CNA C was hired on 9/14/22. CNA C did not have performance evaluations completed for 2024.During a record review of CNA F's employment file, CNA F was hired on 6/9/22. CNA F did not have performance evaluations completed for 2024.During a record review of CNA G's employment file, CNA G was hired on 5/5/05. CNA G did not have performance evaluations for 2024.During a record review of CNA H's employment file, CNA H was hired on 6/9/22. CNA H did not have performance evaluations for 2024.During a concurrent interview and record review with Administrator (Admin) on 1/21/26 at 11:41 am, CNAs' personal files were reviewed, the Admin confirmed CNA H did not have performance evaluations completed for 2024 and should have. Admin stated Minimum Data Set Nurse (MDS)/Director of Staff Development (DSD) was supposed to complete performance evaluations every year per facility policy.During a concurrent interview and record revie with MDS/DSD on 1/22/26 at 8:44 am, CNAs' personal files were reviewed. the MDS/DSD confirmed CNA C, F, G, and H did not have performance evaluations for 2024. MDS/DSD confirmed facility policy stated staff were supposed to have annual evaluations, and facility did not follow their policy.

Based on observation, interview and record review the facility failed to maintain the food preparation and service areas in a clean and sanitary condition, when the following was identified:A visibly dirty dishwasher.Visibly soiled fans, including an air-conditioning fan located in the pantry.Dirty hanging light fixtures with visible debris.Visibly soiled ceiling above cooking area.An open container of cheese without proper covering.Resident Refrigerator visibly soiled and holding expired items.This had the potential to contaminate food and place residents at risk for foodborne illness. 1.During a concurrent interview and record review on 1/23/26 at 10:20 a.m. with the Nutritional Services Director (NSD), the facility's policy and procedure titled Dishwashing Machine Operation, dated 2020, was reviewed. The NSD confirmed that the policy indicated the dishwashing machine was to be checked for cleanliness prior to the start of each meal service, wiped down per equipment cleaning procedures, and maintained free of built-up debris and lime scale as necessary. During a concurrent observation and interview, on 1/20/26, at 8:05 a.m., with the NSD, the dishwasher was observed to be soiled on the exterior, with lime scale stains noted on the front and sides of the machine. The NSD confirmed the dishwasher should have been wiped down prior to food service, in accordance with facility policy.2. During a review of the facility's policy and procedure titled Cleaning Instructions: Ceilings and Walls, dated 2020, the policy indicated ceilings were to be cleaned using a mild detergent with germicidal solution at least annually or as needed. Walls were to be cleaned daily to remove dirt, splatters, and food stains, and cleaned and sanitized at least monthly or as needed. In food preparation areas, walls were to be washed, rinsed, sanitized, and allowed to air dry.During a concurrent observation and interview, on 1/20/26, at 8:10 a.m., with the NSD, the air-conditioning unit cover located in the pantry was observed to be visibly dirty, with dust and debris present. A standing fan located next to the dishwasher was also observed to be visibly soiled, with food-like debris and dirt present. The NSD confirmed these items should not have been visibly soiled, in accordance with facility policy.3. During a review of the facility's policy and procedure titled Cleaning Instructions: Ceilings and Walls, dated 2020, the policy indicated ceilings were to be cleaned using a mild detergent with germicidal solution at least annually or as needed. Walls were to be cleaned daily to remove dirt, splatters, and food stains, and cleaned and sanitized at least monthly or as needed. In food preparation areas, walls were to be washed, rinsed, sanitized, and allowed to air dry.During a concurrent observation and interview, on 1/20/26, at 8:05 a.m., with the NSD, the light fixtures located over the cooking areas in the kitchen were observed to be visibly covered with dust. The NSD confirmed cleaning of the light fixtures was the responsibility of the Maintenance Department, and stated the fixtures had not been cleaned due to the type of light fixture.During an interview on 1/21/26, at 11:15 a.m., with Maintenance (MAIN), MAIN stated the light fixtures were fluorescent bulbs and were unable to be cleaned. MAIN stated there was a plan to replace the fluorescent bulbs with LED lighting and confirmed the parts were available but the replacement had not yet been completed. MAIN confirmed this is required to be in compliance with facility policy.4. During a concurrent observation and interview on 1/20/26 at 8:10 a.m. with NSD, in the kitchen above the stove, a bedpan was observed positioned to collect water leaking from the ceiling. Additionally, a lock and chain were observed over a pipe located directly above the cooking range; the pipe was visibly soiled with dust. NSD confirmed that cleaning of these areas is the responsibility of the maintenance department and stated that maintenance was aware of the issue and has been working on the leaking ceiling for several months. NSD further confirmed that these conditions had the potential to contaminate food and food-contact surfaces. During the observation, NSD immediately removed the bedpan, stating that it should not have been present in the food preparation area.During an interview on 1/21/2026 at 11:15 a.m. with MAIN, MAIN acknowledged that the lock and chain observed over the pipe located above the cooking range should be removed and that the pipe should be painted to allow for proper cleaning, in accordance with the facility's policy related to maintenance and sanitation of the physical environment. MAIN further acknowledged awareness of the leaking ceiling and stated that attempts had been made to correct the issue, including repairs with sheetrock, and confirmed that maintenance had been addressing the leaking ceiling over an extended period of time.5. During an observation on 1/20/2026 at 8:05 a.m. during the initial kitchen tour, an open container of sliced cheese was observed in the kitchen refrigerator.During a concurrent interview and record review on 1/23/2025 at 10:00 a.m. with NSD, the facility's policy and procedure related to the storage of dairy products was reviewed. The policy indicated that refrigerated cheese is to be kept tightly packaged. NSD confirmed that the sliced cheese observed in the kitchen refrigerator on 1/20/2026 was not covered or stored in accordance with the facility policy.6. During a review of the facility's policy and procedure titled Refrigerators in Resident Rooms (Nurses Fridge), dated 2020, the policy indicated the facility was to monitor resident room refrigerators daily for temperature compliance, discard food items maintained outside acceptable temperature ranges or past their use-by date, discard leftover food after three days, and ensure refrigerators were cleaned and sanitized by housekeeping at least monthly or as required. During a concurrent observation and interview on 1/22/2026 at 3:00 p.m. with Assistant Director of Nursing (RN M), at the nurses' station while reviewing the resident food refrigerator used to store food brought in from outside the facility, the refrigerator was observed to be visibly dirty. RN M confirmed that the condition was not acceptable and that multiple food items observed were expired and should have been discarded after three days in accordance with facility policy.

Based on interview and record review, the facility failed to ensure accurate documentation of psychiatric (mental health) diagnosis in the medical records for one out of 30 sampled residents (Resident 6) based on standards of practice. This failure could lead to inaccurate treatment and monitoring of Resident 6's psychotropic (medications that affect mood or behavior) medication use.Review of Resident 6's medical record, titled Order Summary Report (a list of all doctor orders and medical conditions), dated 1/2026, the record indicated Resident 6 was on a medication called Seroquel (or quetiapine, a medication used to treat the mood and mental health issues) for bipolar disorder (a chronic mental illness that fluctuated between depression and anxiety) as follow: SEROquel Tablet 25 MG (quetiapine; MG means milligram, a unit of measure); Give 2 tablets by mouth at bedtime for Bipolar m/b (manifested by) manic episodes (mania means abnormally elevated, euphoric, or irritable mood, accompanied by intensely high energy and activity levels) . start date : 2/13/2025. Further review of the records indicated Seroquel originally was started on 9/13/23 about one month after admission to the facility and the dosage was increased on 2/13/25.Review of Resident 6's medical record, titled History and Physical (a summary of medical condition upon admission), dated 8/24/23, the record written by Medical Doctor 1 (MD 1), indicated okay to use hospital H&P from 8/24/23.Review of Resident 6's medical record, titled History and Physical (a summary of medical conditions written by a medical doctor) from hospital upon admission to the facility, dated 8/24/23, the record did not include any reference to diagnosis of bipolar disorder.Review of a Resident 6's medical record for a neuropsychiatric consultation (a medical specialist for mental and brain health), dated 9/5/23, the record indicated the diagnosis of Lewy Body dementia (a type of memory loss leading to fluctuations in cognitive function, visual hallucinations, movement issues similar to Parkinson's, and sleep disruptions), epilepsy (or seizure, a surge in brain activity), and parkinsonism (nerve damage affecting body movement and tremors). The record did not include bipolar disorder. The neuropsychiatric doctor started Seroquel on September of 2023.Review of Resident 6's electronic medical record under Medical Diagnosis section, on 1/22/26, indicated Bipolar Disorder, Current Episode manic without Psychotic Feature, Mild, Created date: 9/13/23; Classification: During Stay.Review of the Resident 6's medical record, titled Medication Administration Record (or MAR), dated 1/2026, the record on nurses' behavior monitoring for manic episodes indicated no manic behaviors were documented during day and evening shifts. The MAR did not define what specific behavior the nursing staff should have monitored.Review of Resident 6's Care Plan Report (a nursing plan of care), dated 1/2026, the document written by facility's social worker, indicated The resident has a behavior problem OF MANIC BEHAVIOR, CONFABULATING STORIES r/t (related to) BIPOLAR DX (DX means diagnosis). The plan of care interventions indicated to Administer medications as ordered. Monitor/document for side effects and effectiveness. The care plan did not address what type confabulation stories nursing staff were dealing with.In an interview with Certified Nurse Assistant N (CNA N), on 1/22/26, at 8:40 AM, CNA N stated Resident 6 was easy to work with, pleasant, cooperative and had not seen her being aggressive. CNA N stated Resident 6 mostly stayed in her room and when she went to dine, she preferred to sit with two specific residents.In an interview with Licensed Nurse J (LN J), on 1/22/26, at 9:05 AM, LN J stated Resident 6 wanted things her way and often resisted change. LN J stated Resident 6 often felt being abandoned by her family and they were ignoring her. LN J stated Resident 6 was not aggressive.In an interview with Patient 6, in her room, on 1/22/26, at 8:45 AM, Patient 6 stated it was hard for her to live after her husband passed away and she missed him. Resident 6 didn't know much about the medication she was taking.In an interview with Director of Nursing (DON), in her office, on 1/22/26, at 10:50 AM, the DON stated Resident 6 had repeatedly expressed wishes to die and currently is on comfort care based on her wish and her sister who regularly visited her in the facility. The DON could not comment on documentation of diagnosis and monitoring of mania behavior in the medical record. The DON stated the mental health evaluation and regular psychotherapy visit was facilitated by the facility.In an interview with Medical Doctor 1 (MD 1), on 1/22/26, at 1:48 PM, MD 1 stated the mental health issues were pre-existing and upon admission a neuropsychiatric evaluation was performed. MD 1 stated the family, and her sister may know better the history of mental illness prior to admission to the facility. MD 1 stated Resident 6 may have had two episodes of low-level mania that may have contributed to the bipolar diagnosis. MD 1 acknowledged the initial neuropsychiatric consult did not address the bipolar diagnosis.Review of the facility's policy, titled Antipsychotic Medication Use, dated 4/2007, the policy indicated Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, symptoms and risks. Attending physician and facility staff will identify acute psychiatric episodes and will differentiate them from enduring psychiatric conditions. Nursing staff will document in detail an individual's target symptoms. The attending physician will identify evaluate and document with input from other disciplines and consultant as needed, symptoms that may warrant the use of antipsychotic medications .The review of the American Psychiatric Association (APA, a nationally recognize mental health organization which establishes the authoritative standards for mental health diagnoses) practice guidelines, titled The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults, dated 8/2015, last accessed via https://psychiatryonline.org/doi/epdf/10.1176/appi.ajp.2015.172050, the guideline indicated proper diagnosis involves assessing psychiatric symptoms, medical health, and the patient's social and cultural context, as well as their functional impairment.

Based on interview, and record review, the facility failed to ensure accurate documentation and ongoing pain assessment for one of five residents reviewed for unnecessary medication use (Resident 31).This failure had the potential for unsafe mediation use and risk of adverse effects from opioid use including difficulty breathing and mental confusion. Findings: During a review of Resident 31's medical record indicated that Resident 31 was admitted to the facility on [DATE] with diagnoses that included respiratory failure (a serious condition where the lungs can't pump enough oxygen into the blood), chronic obstructive pulmonary disease (COPD - a progressive lung disease that restricts airflow, making it difficult to breath), diabetes (blood sugar disease), in addition to chronic pain. During a record review of the Resident 31's Order Summary Report, dated 1/2026, the record indicated the following pain medication orders: Morphine Sulfate . Oral Solution 20 MG/ML (opioid pain medication; MG/ML is milligram per milliliter, a measure of strength); Give 0.25 ml ( ml is milliliter, a measure of volume) by mouth every 4 hours as needed for Mild Pain Hold for RR<12 ( RR means respiratory rate- or breathing rate) AND Give 0.5 ml by mouth every 4 hours as needed for Moderate Pain Hold for RR<12 AND Give 0.75 ml by mouth every 4 hours as needed for Severe Pain Hold for RR<12; Start date 09/19/25 Norco Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen, combination pain medication with opioid); Give 1 tablet by mouth every 12 hours for Chronic Pain . Hold for RR<12; Start date: 5/23/24The Norco order did not prompt the nursing staff to document pain level with each dose administered.During a review of Resident 31's electronic medical record under Pain Level Summary, with a date range of 10/24/25 to 1/21/26, indicated that Resident 31's pain was a 0 (no pain) on a scale of 0 to 10 (excruciating pain) every day. During a review of Resident 31's electronic medical record under Post Fall Review, dated 12/17/25, indicated that Resident 31 had a history of falls. The review did not identify narcotics as a medication that may have contributed to the fall. During an interview on 1/22/26 at 8:52 am with Resident 31, Resident 31 was laying in bed in their room and confirmed that they do have pain every day. Resident 31 stated the pain can range from an 8 to a 10 on a scale of 0 to 10. Resident 31 stated that their pain can be in her feet, lower back, and finger. During an interview with Licensed Nurse (LN) J, on 1/22/26 at 9:04 am, LN J stated Resident 31 will let nursing staff know if pain medication is needed. LN J confirmed that they did not check Resident 31's pain level when opioid pain medication was administered. LN J could not explain why Resident 31 was documented with a pain level of 0 every day for the past two months. During an interview on 1/22/26 at 9:28 am with the Director of Nursing (DON), the DON stated that for any scheduled pain medication staff only needed to assess pain once a shift. The DON stated the interdisciplinary team (IDT - healthcare team) was responsible for addressing pain management issues and recurrent falls episodes. The DON confirmed that at the last IDT meeting on 11/23/25 for Resident 31, they did not discuss pain management, and they should have assessed recurrent falls along with opioid medication use. During a review of the facility policy titled Pain Assessment and Management, dated 10/2010 indicated that a comprehensive pain assessment should be conducted upon admission., at the quarterly review, whenever there is a significant change in condition, and whenever there is a new onset of pain or worsening of existing pain. Monitor the residents' pain by performing a basic assessment with enough detail. If pain symptoms have resolved or there is no longer an indication for pain medication, the multidisciplinary team and physician shall try to discontinue or taper pain medications to the extent possible.

Based on interview and record review, the facility failed to ensure safe use and accountability of narcotic controlled medication (opioid drugs of abuse) use when: Resident 46's Norco (a combination opioid pain medication) was removed from the Controlled Drug Record (CDR - an accountability sheet that tracked narcotic removal with nurse initial, date, and time) without the corresponding documentation in the Medication Administration Record (MAR - a legal document where nursing staff documented medications given to residents). This failure had the potential to contribute to unsafe drug handling, poor pain control, and risk of drug diversion (drug loss). Findings:During a review of Resident 46's medical record indicated that Resident 46 was admitted to the facility on [DATE] with diagnoses that included arthritis, chronic pain, and diabetes (blood sugar disease). A review of Resident 46's MAR, dated 1/2026, indicated the following order for pain management: Norco. take one tablet by mouth every four hours as needed.; Start date 12/11/25. During a record review of Resident 46's CDR for Norco pain medication, with the date range of 12/20/25 to 1/20/26, the CDR record listed Norco removal for PRN (as needed) use. A comparative review of Resident 46's CDR and MAR for the same time period, indicated the following:1/7/26 at 1600 (4:00 pm); no MAR documentation 1/9/26 at 2140 (9:40 pm); no MAR documentation 1/15/26 at 1500 (3:00 pm); no MAR documentationThe record indicated Norco removal from the CDR with no corresponding documentation in the MAR. During a concurrent interview and record review with the Director of Nursing (DON) on 1/22/26 at 12:31 pm, the DON confirmed that Norco removal documentations were missing from the MAR on 1/7/26, 1/9/26, and 1/15/26 and it should have been documented in the MAR to match the CDR. During review of the facility policy titled Administering Medications, dated 12/2012 indicated when an individual administers a medication, they must initial the residents MAR on the corresponding line after it is given before giving the next medication.

Based on observation, interview and record review, the facility failed to ensure safe storage of medication and supplies with a census of 52 residents when:Medication room refrigerator stored expired and discontinued medications, and the refrigerator temperature was not monitored twice daily for vaccine storage.Medication cart stored undated and expired medications. These failures had the potential to contribute to unsafe medication use and risk of ineffective medications reaching vulnerable residents in the facility. Findings: 1a. During a concurrent inspection of facility main medication room accompanied by the Assistant Director of Nursing (ADON), on 1/20/26 at 9:23am, the following issues were noted: a. a bag of Vancomycin (antibiotic in injection form) had expired on 1/1/26. b. an open vial of Tuberculin Purified Protein Derivative Solution (PPD - testing agent for tuberculosis a dangerous lung disease) dated 9/11/25. The manufacturer label on the vial indicated that the vial should be discarded 30 days after being opened. The ADON acknowledged the findings and stated that outdated medications should have been removed from active medication storage areas. 1b. Review of the monitoring log of the medication refrigerator temperature, posted on the refrigerator door, dated 1/2026, the log indicated the refrigerator temperature was monitored and recorded once a day. The medication refrigerator was storing vaccines. The ADON stated they were not aware of twice daily temperature monitoring and documentation for storing vaccines in the medication refrigerator. 2.During a concurrent inspection of medication cart on the facility's south hall, on 1/20/26 at 2:27 pm, accompanied by Licensed Nurse (LN) J. The following were noted: a. Three bottles of unopened eye drop medication called Latanoprost (drug for eye disease) when the drug label on the bottle indicated to keep refrigerated until opened. b. One bottle of eye drop medication Latanoprost had an open date of 11/6/25 when the medication label indicated to discard the eye drops six weeks after it had been opened. c. Four bags of DuoNeb (drug used to help with breathing difficulties) were opened, out of foiled wrap and did not have an open date. Manufacturer label indicated the medication was to be discarded two weeks after opening. d. One Insulin Glargine (long-acting drug for blood sugar disease) pen had an open date of 12/8/25 when the manufacturer label indicated to discard 28 days after being opened. e. One bottle of Acidophilus with Pectin (probiotic used to help with gut health) was opened and stored in the medication cart when the label on the bottle indicated to keep refrigerated after opening. LN J acknowledged the findings and stated the staff should have been more vigilant with reading the medication storage labeling. During a concurrent interview and record review on 1/22/26 at 9:28 am with the Director of Nursing (DON), the DON confirmed that Latanoprost needed to be stored in the refrigerator until opened and follow the manufacture beyond use date of six weeks after being opened. The DON stated Insulin needed to be discarded 28 days after being opened per the manufacturer label. The DON stated the nursing staff should have followed manufacturing labeling to keep Acidophilus with Pectin refrigerated once opened. The DON stated DuoNeb should have been dated once opened and out of the foil wrap per drug manufacturer instruction. During a review of the facility policy titled Storage of Medication, dated 4/2007, the policy indicated the facility shall not use discontinued, outdated, or deteriorated drugs. all such drugs shall be returned to the dispensing pharmacy or destroyed. Medications requiring refrigeration must be stored in a refrigerator. Review of the Center for Disease Control (or CDC, a federal agency with mission to protect public health) guideline, titled Vaccine Storage and Handling Toolkit; Vaccines Storage and Handling Information dated 3/29/24, last accessed on 1/27/26 via https://www.cdc.gov/vaccines/hcp/downloads/storage-handling-toolkit.pdf , the document indicated Checking and recording minimum/maximum temperatures at start of each workday . Reviewing and analyzing temperature data at least weekly for any shifts in temperature trends. The document further indicated Check and record storage unit minimum and maximum temperatures at the start of each workday. If your TMD (Temperature Monitoring Device) does not read minimum/maximum temperatures, then check and record the current temperature a minimum of two times per workday (at the start and end of the workday).During a review of the facility policy titled Administering Medications, dated 12/2012 indicated that when opening a multi-dose container, the date opened shall be recorded on the container.

Based on observation, interview and record review the facility failed to ensure compliance with infection prevention practices with census of 52 residents when:1. Blood Pressure (or BP, the force of blood pushing against the walls of arteries as the heart pumps it around the body) device cuff was not cleaned after Resident 46 use.2. The pill cutter stored in the medication cart had white powder like residues inside the device.These failed practices could contribute to unsafe care and spread of infection in the facility.Findings:1. During a medication administration observation, in South hall, accompanied by Licensed Nurse J (LN J), on 1/20/26, at 8:33 AM, LN J took up a blood pressure device into the Resident 46 room. LN J wrapped the BP cuff around Resident 46's arm and measured the blood pressure. LN J upon exit from the room, placed the BP device/cuff on where two other BP cuffs hanging on the side of the mobile medication cart. LN J did not clean the BP cuff and continued with medication administration.In an interview with LN J, in the South hall, on 1/20/26, at 8:55 AM, LN J stated the BP cuff should have been cleaned after each use in between residents. 2. During a medication cart inspection, in the South hall, accompanied by LN J, on 1/20/26, at 2:27 PM, the shared pill cutter device had significant amount of white powder and dust inside the device. LN J stated the pill cutter was shared and used to splitting the pills when needed. LN J stated the pill cutter should have been cleaned after each use. In an interview on 1/22/26 at 9:45 AM, the Director of Nursing (DON) stated that staff should have followed infection prevention practices when cleaning shared patient care devices like BP cuffs and pill cutters. BP cuffs should have been cleaned with Sani-wipes (purple) after each use, staying wet for about 2 minutes. A second cuff should be used alternately. BP cuffs must be cleaned immediately and kept separate from clean ones. The DON also noted that pill cutter dust must be wiped to prevent cross-contamination.Review of the facility's policy, titled Infection Control Guidelines for All Nursing Procedures, dated 4/2013, the policy indicated Standard Precautions will be used in the care of all residents in all situations, regardless of suspected or confirmed presence of infectious diseases. Standard precautions apply to blood, body fluids, secretions and excretions regardless of whether or not they contain visible blood, non-intact skin and/or mucous membranes.Review of the facility's policy, titled Administering Medications, dated 12/2012, the policy under Infection Control Practices indicated Staff shall follow establish facility infection control procedures (handwashing, antiseptic techniques, gloves, isolation precaution, etc.) for the administration of medication, as applicable.

Based on observation and interview, the facility failed to provide a clean, safe, comfortable, and homelike environment for seven of 18 sampled residents (Residents 12, 18, 19, 31, 34, 42, and Resident 153) when: 1. Four of Four stand up mechanical lifts were unclean. 2. Patio doors to multiple resident rooms were unkept and unclean with cumulative dust and dark and brown debris. 3. Cumulative food and debris was on the floor and under the wooden side table in room [ROOM NUMBER] A. 4. A side table was unkept, faded, with visible chips in the wood in room [ROOM NUMBER] A. 5. Tile was missing on the floor in room [ROOM NUMBER] A. 6. A foot board was unkept, damaged, and had visible chips in the wood in room [ROOM NUMBER] A. 7. Resident privacy curtains had visible red and brown colored stains. 8. The curtains and tracks of the sliding glass doors in the resident rooms were unclean. This failure had the potential to negatively affect client's health, safety, and comfort and the potential to spread other bacteria in the facility to other residents, staff, visitors, and the community. Findings: 1. A review of the facility's policy revised 8/2010, titled, Cleaning and Disinfection of Resident-Care Items and Equipment, indicated resident-care equipment, including reusable items and durable medical equipment (DME) will be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC) recommendations for disinfection and the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard. DME must be cleaned and disinfected before reused by another resident. Reusable resident care equipment will be decontaminated and/or sterilized between each residents according to manufacturer's instructions. During an observation on 1/7/25 at 10:11 am on the south hall, four of four stand up lifts were unclean with visible dried food particles, cumulative dust, and brown and black colored debris. During an interview on 1/7/25 at 10:12 am, Certified Nursing Assistant (CNA) A confirmed four stand up lifts used to transfer residents were unclean, with cumulative food, dust and debris and these lifts were shared by residents who need this lift for safety for transfers in and out of bed. During an interview on 1/7/25 at 10:45 am, the Director of Nursing (DON) confirmed the mechanical stand up lifts need to be cleaned and sanitized after each use for each resident and two times daily. DON confirmed not cleaning equipment could lead to the spread of infection to other residents and everyone in the facility. 2. A review of the facility's policy revised 8/2010, titled, Cleaning and Disinfection of Environmental Surfaces, indicated environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of health care facilities and the OSHA Bloodborne Pathogens Standard. This policy indicated Housekeeping surfaces to include floors, tabletops, will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. Environmental surfaces will be disinfected or cleaned on a regular basis such as daily or three times weekly, and when surfaces are visibly soiled. Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. During an observation on 1/7/25 from 10:15 am to 10:23 am, the patio sliding door windows, tracks, and corners of rooms for residents in Rooms 14, 15, 16, 17, 18, and room [ROOM NUMBER] were unkept and unclean with cumulative dust and dark brown debris. The sliding glass was not clean with visible dust and grime build up. During a follow up interview on 1/8/25 at 12:20 pm, the admin and House Keeping Supervisor (HS) confirmed all of the resident's environment including rooms, floors, sliding glass doors and the tracks of the sliding doors need a deep cleaning. HS stated, The policy does not include deep cleaning, but I will make sure all rooms are deep cleaned on a schedule and as needed moving forward. 3. During an observation on 1/7/25 at 10:37 am, there was cumulative food and debris on the floor and under the wooden side table in room [ROOM NUMBER] A. During an interview on 1/7/25 at 11:05 am, the Administrator (admin) confirmed there was a build up of food and debris in room [ROOM NUMBER] A. Admin stated, [Resident 42] needs assistance with feeding, and she drops cookie crumbs in her room. 4. During an observation on 1/7/25 at 10:42 am, the wooden side table (nightstand) beside the bed was unkept, faded, with visible chips in the wood in room [ROOM NUMBER] A. During an interview on 1/7/25 at 11:00 am, the admin confirmed the nightstand for Resident 42 needed to be repaired to be cleaned properly and was unkept. The admin stated, I have already ordered many new nightstands for multiple residents, and they should be here in a week or so, it has already been approved. 5. During an observation on 1/7/25 at 10:49 am, the floor under the bed in room [ROOM NUMBER] A was missing two tiles underneath the bed of Resident 18. During an interview on 1/7/25 at 11:00 am, the admin confirmed the floor tiles needed to be replaced in room [ROOM NUMBER] A to be cleaned properly for Resident 18. 6. During an observation on 1/7/25 at 10:52 am, the foot board of the bed for Resident 12 was unkept, damaged, and had visible chips in the wood in room [ROOM NUMBER] A. During an interview on 1/7/25 at 11:00 am, the admin confirmed the foot board for Resident 12 was unkept, damaged, and needed repair. During a follow up interview on 1/8/25 at 12:20 pm, the admin and House Keeping Supervisor (HS) confirmed all of the resident's environment including rooms, floors, sliding glass doors and the tracks of the sliding doors need a deep cleaning. HS stated, The policy does not include deep cleaning, but I will make sure all rooms are deep cleaned on a schedule and as needed moving forward. 7. During a follow up interview on 1/8/25 at 12:30 pm, the admin and HS confirmed resident privacy curtains needed to be replaced if washing the curtains are not removing visible stains. HS stated, We wash the privacy curtains, and it takes about 30 minutes to air dry, but we need more curtains if they are replaced, some of the stains will not come out during washing them. 43031 8. During an observation on 1/7/25 at 10:48 am, in resident room [ROOM NUMBER], the track to the sliding glass door opening to the patio, appeared to be unclean and have an accumulation of dark brown dirt and debris. During a concurrent observation and interview on 1/7/25 at 11:00 am, with Resident 153 and Family Member (FM) in Resident 153's room [ROOM NUMBER], the sliding glass door track appeared to be unclean with an accumulation of dark brown dirt and debris. Resident 153 and FM stated, we have been here for 3 weeks and the glass door track has been dirty the entire time. During a concurrent observation and interview on 1/7/25 at 11:00 am, with Resident 153 and Family Member (FM) in Resident 153's room [ROOM NUMBER]. The off-white curtain to the sliding glass door was observed with a reddish-brown stain that appeared to have been blotted or cleaned but the stain remained. Resident 153 and FM stated, we have been here for 3 weeks and the stain on the curtain has been here the whole time. It is very noticeable; we have commented to staff, but it is very evident and anyone can see it. I think it is blood on the curtain. It looks like they tried to clean it with something which lightened it and turned it more brownish, but it is very unclean. During a concurrent observation and interview on 1/7/25 at 12:23 pm, with CNA C in room [ROOM NUMBER], the soiled curtain and sliding glass door track were observed. CNA C stated, I am not sure what is on the curtain, it looks brownish. It is dirty. The door track is definitely dirty, I don't know if anyone cleans it. All of them look like that.

Based on observation, interview and record review, the facility failed to ensure that Resident 19 was administered an inhaler without following manufacturer's instructions to meet Professional Standards of Care. This failure resulted in and had the potential for the medication to be ineffective for all residents that were ordered an inhaler routinely or as needed (prn). Findings: During a review of a policy revised 10/2021, titled, Administering Medications through a Metered Dose Inhaler, indicated the purpose of this procedure is to provide guidelines for the safe administration of inhaled medications. This policy indicated to explain the procedure to the resident. Administer the medication as follows: Shake the inhaler gently to mix the medication ., remove the cap from the mouthpiece, ask the resident to inhale and exhale deeply for a few breath cycles, on the last cycle, instruct the resident to exhale deeply. Instruct the resident to close his or her lips to form a seal .depress the medication .instruct the resident to inhale deeply and hold for several seconds. Rinse the mouthpiece with warm water. During a review of a record not dated, titled, Albuterol Inhaler Instructions For Use, indicated the following: Shake the inhaler hard 10 to 15 times before each use. Breathe out all the way. Try to push out as much air as you can. Breathe in slowly, Hold the inhaler with the mouthpiece down. Place your lips around the mouthpiece so that you form a tight seal. As you start to slowly breathe in through your mouth, press down on the inhaler one time. Keep breathing in slowly, as deeply as you can. Hold your breath, Take the inhaler out of your mouth. If you can, hold your breath as you slowly count to 10. This lets the medicine reach deep into your lungs. Pucker your lips and breathe out slowly through your mouth. If you are using inhaled, (beta-agonists), wait 1 to 2 minutes before you take your next puff. You do not need to wait between puffs for other medicines. Put the cap back on the mouthpiece and make sure it is firmly closed. After using your inhaler, rinse your mouth with water, gargle, and spit. Do not swallow the water. This helps reduce side effects from your medicine. A review of Resident 19's clinical record indicated Resident 19 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD, a progressive lung disease), muscle weakness, hypercalcemia (high calcium levels in the blood), heart disease and depressive episodes (constant feelings of sadness, loss of interest in doing activities). This record also indicated Resident 19 is his own responsible party (able to make medical decisions). During a review of Resident 19's medical record a document dated 1/9/25, titled, Active Orders, indicated Albuterol Sulfate 90 micrograms (Mcg, a unit of measurement) one puff every 4 hours inhalation as needed for wheezing. During an observation on 1/9/25 at 7:20 am, Licensed Nurse (LN) 2 handed the inhaler medication albuterol 90 mcg to Resident 19 as ordered, and did not provide any instructions for Resident 19 for breathing techniques for effectiveness and per manufacturer's guidelines as follows: Before you breathe in your dose from the inhaler, breathe out (exhale) as long as you can, inhale one puff of the albuterol inhaler, remove the inhaler from your mouth and hold your breath for about 10 seconds, or for as long as comfortable for you. Breathe out slowly as long as you can. During an interview on 1/9/25 at 9:05 am, the Director of Nursing (DON) confirmed the medication for Resident 19's inhaler was not administered correctly by LN 2 by not giving specific breathing instructions. DON stated, Resident 19 has COPD, and he might need a spacer, but I will do an inservice to all nurses to correctly administer all inhalers for effectiveness.

Based on observation, interview, and record review, the facility failed to ensure oxygen equipment was monitored, changed, and dated as ordered for two out of five sampled residents (Resident 1 and Resident 34) when: 1. The oxygen tubing for Resident 1 was dated 12/25/24 during an observation on 1/7/25. 2. The oxygen bottle for Resident 34 was empty, not full of bubbling water and dated 12/1/24, and the oxygen tubing for Resident 34 was dated 12/25/24. This failure had the potential to cause discomfort, and the spread of infection to the residents, staff, and visitors. Findings: 1. A review of the facility's policy revised 10/2010, titled, Oxygen Storage and Use, indicated the purpose of this policy is to provide safe storage and use of oxygen equipment. A review of Resident 1's medical record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included surgical aftercare of the digestive system, a colostomy (an opening for bowel elimination), diabetes, Chronic Pulmonary Obstructive Disease (COPD, a progressive lung disease), and heart disease. A review of the most recent Minimum Data Set, (MDS, a resident assessment tool) for Resident 1 dated 10/4/24, indicated that Resident 1 had a moderate cognitive deficit, with a brief interview for mental status (BIMS) score of 8 out of 15, and needed moderate assistance from staff with all activities of daily living (ADLs, basic needs as personal hygiene, dressing, toileting, transferring, walking, and eating). A review of Resident 1's medical record indicated a document dated 1/2025, titled, Active Orders, indicated Resident 1 was ordered Oxygen 2 liters (l) via nasal canula (n/c) to maintain oxygen levels above 90%. A review of Resident 1's medical record indicated a document dated 1/2025, titled, Active Orders, indicated Resident 34 was ordered change oxygen tubing every seven days and date and label all components every week on Tuesday. During an observation on 1/7/25 at 11:14 am, the oxygen tubing being used by Resident 1 was dated 12/25/24, seven days late being changed per the facility policy and orders. During an interview on 1/7/25 at 3:15 pm, the Director of Nursing (DON) confirmed the oxygen tubing needed to be changed for Resident 1, dated 12/25/24 every seven days and as needed. 2. A review of the facility's policy revised 10/2010, titled, Oxygen Administration, indicated the purpose of this procedure is to provide guidelines for safe oxygen administration. The following equipment and supplies will be necessary when performing the procedure humidifier bottle. Check the mask, tank, humidifying jar to be sure they are in good working order and securely fastened. Be sure there is water in the humidifying jar and the water level is high enough that the water bubbles as oxygen flows through Periodically re-check water level in the humidifying jar. Report other information in accordance with facility policy and professional standards of practice. A review of Resident 34's medical record indicated Resident 34 was admitted to the facility on [DATE] with diagnoses that included palliative care (specialized medical care for serious illness), acute respiratory failure (a condition when the lungs cannot get enough oxygen in the blood), heart disease, dependence on oxygen therapy, and dysphagia (difficulty swallowing). A review of the most recent MDS, for Resident 34 dated 9/15/24, indicated that Resident 34 had a moderate cognitive deficit, with a BIMS score of 10 out of 15, and needed maximum assistance from staff with all activities of daily living (ADLs, basic needs as personal hygiene, dressing, toileting, transferring, walking, and eating). A review of Resident 34's medical record indicated a document dated 1/2025, titled, Active Orders, indicated Resident 34 was ordered Oxygen 2 l via n/c to maintain oxygen levels above 90%. A review of Resident 34's medical record indicated a document dated 1/2025, titled, Active Orders, indicated Resident 34 was ordered change oxygen tubing every seven days and date and label all components every week on Tuesday. During an observation on 1/7/25 at 11:55 am, the oxygen water humidifier bottle was empty, there was no water present, and the date on the water bottle was 12/1/24. The oxygen tubing being used by Resident 34 was dated 12/25/24. During an interview on 1/7/25 at 2:54 pm, Licensed Nurse (LN) 4 stated, Our oxygen policy is change every Sunday on noch shift, but we should double check to make sure it is done for all residents using oxygen. The oxygen tubing and bags on the bedside and on wheelchairs and the water bottles should be changed every week. LN 4 confirmed not changing oxygen equipment per policy could cause an infection for residents that require oxygen administration. During an interview on 1/7/25 at 3:17 pm, the DON confirmed the oxygen water bottle humidifier for 34 should have never run low on water and needed to be changed. The DON also confirmed the oxygen tubing Resident 34 was using needed to be changed and any equipment not changed as ordered and per policy could cause a respiratory infection including pneumonia. DON stated, I will re-educate all the nurses because it is on the Treatment Administration Records to document, and the oxygen equipment should be changed per the orders.

Based on interview and record review, the facility failed to document behaviors for an antipsychotic (medication used for moods and behaviors to treat mental illness) medication used for one of three sampled residents (Resident 31). This failure had the potential to not identify an increase in behaviors, identify new interventions needed, and a change in condition that should be reported to the physician for medication management. Findings: A review of the facility's policy revised 12/2016, titled, Antipsychotic Medication Use, indicated residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications. A review of the facility's policy revised 12/2016, titled, Behavioral Assessment, Interventions, and Monitoring, indicated behavioral symptoms will be identified using the facility approved behavioral screening tools and the comprehensive assessment. The facility will comply with regulatory requirements related to the use of medications to manage behavioral changes. This facility policy also indicated 10, .when medications are prescribed for behavioral symptoms, documentation will include and specific target behaviors and expected outcomes, and monitoring for efficacy and adverse consequences. A review of Resident 31's medical record indicated Resident 31 was admitted to the facility on [DATE] with diagnoses that included diabetes (too much sugar in the blood), high blood pressure, epilepsy (seizures), Parkinson's disease (a progressive brain disorder that causes involuntary movements such as shakiness and tremors) and Bi-Polar disorder (a mental health condition that causes extreme mood swings). A review of the most recent Minimum Data Set, (MDS, a resident assessment tool) for Resident 31 dated 11/20/24, indicated that Resident 31 had a very mild cognitive deficit, with a brief interview for mental status (BIMS) score of 13 out of 15, and needed moderate assistance from staff with all activities of daily living (ADLs, basic needs as personal hygiene, dressing, toileting, transferring, walking, and eating). A review of Resident 31's medical record indicated a document dated 1/2025, titled, Active Orders, indicated Resident 31 was ordered Seroquel (an antipsychotic medication used for moods and behaviors) 25 milligrams (mg, a unit of measure) give one tablet by mouth at bedtime. A review of Resident 31's medical record indicated documents dated 10/1/24 through 1/7/25, titled, Medication Administration Record (MAR), indicated only one behavior was documented on 11/16/24 for monitoring of manic (sudden and severe changes in mood, such as going from being joyful to being angry and hostile. Restlessness. Rapid speech and racing thoughts) episodes. During an interview on 1/9/25 at 9:20 am, the Director of Nursing (DON) confirmed the behaviors by Resident 31 were not documented appropriately on the MARs and she would complete an inservice for all the nursing staff to track specific behaviors and report as indicated. DON stated, They have an area to document behaviors on the MAR, but they are not tracking them. The progress notes for Resident 31 indicate behaviors and the medication is needed for moods.

Based on interview, record review and facility policy review, it was determined that the facility failed to ensure an advance directive was on file for 2 (Resident #26 and Resident #28) of 4 residents reviewed for advance directives. Findings included: A review of a facility policy titled, Advance Directives, revised April 2013, revealed, 3. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives. 4. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 5. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline. 1. A review of an Admission Record indicated the facility admitted Resident #26 on 06/24/2022 with diagnoses that included COVID-19, post COVID-19 condition, paroxysmal atrial fibrillation, essential (primary) hypertension, muscle weakness, and edema. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/27/2023, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident did not have an advance directive. Review of Resident #26's care plan, most recently revised in May 2023, revealed the resident's code status was not addressed. Review of an Advanced Directive Acknowledgment form, dated 06/24/2022, revealed the resident had an advance directive. Review of Resident #26's electronic and hard copy medical records revealed the resident's advance directive was not included in the records. During an interview on 10/10/2023 at 8:54 AM, the MDS Nurse/Staff Development Supervisor (SDS) stated she expected the advance directive documents to be requested during the admission process. During an interview on 10/11/2023 at 10:18 AM, the Social Services Director (SSD) stated the Activity Director/Admissions (AD/Admissions) employee conducted the admission process with the residents and their families. She said she was unaware Resident #26 had an advance directive until the survey team requested the documentation. She indicated she expected the AD/Admissions employee to ask the family to provide these documents, but she had failed to follow up to ensure Resident #26's advance directive was on file. During an interview on 10/11/2023 at 11:54 AM, the AD/Admissions employee stated she completed the admission process with the residents and their families, which included asking if they had an advance directive. She said she had completed an Advanced Directive Acknowledgement Form for Resident #26. She stated if the resident/family indicated on the form that the resident had an advance directive, she assumed the advance directive was obtained during the admission process. During an interview on 10/12/2023 at 10:15 AM, the Director of Nursing (DON) stated she thought there was a communication breakdown because the AD/Admissions employee did not know she had to request the advance directives from the residents or families. During an interview on 10/12/2023 at 10:50 AM, the SSD stated the AD/Admissions employee thought the facility already had residents' advance directives on file and had not requested the documents from the residents or their families. 45555 2. A review of an Admission Record revealed the facility admitted Resident #28 on 09/12/2022 with diagnoses that included malignant neoplasm (cancer) of the lung and chronic obstructive pulmonary disease. The significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/22/2023, revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. Review of Resident #28's care plan revealed a focus area with an initiation date of 09/13/2022 that indicated the resident did not have an advance directive. Interventions included that if the resident did not have an advance directive, the social worker would offer information on how to get one. A review of Resident #28's Advanced Directive Acknowledgement form revealed the resident had an advance directive. The form was signed by the Activity Director/Admissions (AD/Admissions) employee on 09/12/2022. A review of Resident #28's paper chart and electronic health record (EHR) revealed no copy of the resident's advance directive. During an interview on 10/11/2023 at 1:01 PM, Resident #28 stated they had an advance directive, and that the facility should have a copy of it. The resident stated if the facility did not have a copy, their family member could bring one in. During an interview on 10/11/2023 at 11:56 AM, the AD/Admissions employee stated she assisted with admissions by completing the admission paperwork, and that included asking the residents if they had an advance directive and completing the acknowledgement forms. She stated she assumed the advance directives were already sent by the hospital as part of the residents' admission packets. During an interview on 10/11/2023 at 10:41 AM, the Social Service Director (SSD) stated she was not aware that Resident #28 had an advance directive, and she was going to call the resident's family member to see if she could obtain a copy. At 10:52 AM, the SSD stated she had called and left a message with the family member. During an interview on 10/12/2023 at 10:50 AM, the SSD stated the breakdown with the facility obtaining copies of residents' advance directives was due to the AD/Admissions employee thinking the facility already had them and she was therefore not requesting them. During an interview on 10/12/2023 at 10:15 AM, the Director of Nursing (DON) stated an advance directive was a resident's health care directive for their medical wishes. She stated the AD/Admissions employee went over advance directives with residents during the admission process. She stated there was a communication breakdown with the AD/Admissions employee because she did not know she was supposed to request a copy of the advance directive at the time of admission.

Based on interview and record review, the facility failed to ensure that residents who entered the facility did not develop a pressure ulcer (bedsore, localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and friction), received necessary treatment and services to promote healing, and that the pressure ulcers did not worsen or become infected for Resident 1. The Nursing staff failed to adequately assess and identify that excoriation (redness) on a bony prominence, such as the coccyx, was a Stage I (an area of persistent redness) pressure ulcer. The Nursing staff failed to implement timely care planning related to skin assessment and risk factors and the physician was not made aware of worsening wound conditions. These failures resulted in Resident 1 being hospitalized with a Stage IV (full thickness skin loss due to dead tissue or damage to muscle/bone) pressure ulcer which required surgical intervention and antibiotic treatment, after being in the facility for three weeks. Findings: The facility policy titled Wound and Skin Management release date 9/1/2010, indicated the purpose was to maintain or improve tissue tolerance to pressure to prevent injury and or infection and to assure that skin breakdown or potential for skin breakdown was identified on admission and weekly thereafter as needed. The policy described a Stage I pressure ulcer as a defined area of persistent redness that is non-blanchable (does not disappear when pressure is relieved or does not blanch when pressure is applied), may include changes in one or more of the following: skin temperature warmth or coolness, tissue hard or firm (induration), and presence of pain. The policy indicated the Licensed Nurse (LN)/treatment nurse would document pressure ulcer/other skin conditions at least every seven days and should include in detail: Status of ulcer sites and effectiveness of treatment, location, size, Stage the pressure ulcer/sore, and describe drainage. The Interdisciplinary Team (IDT) would enter all skin related issues on the resident's care plan and there would be an interdisciplinary approach to skin care. The policy indicated under interventions in the event a Stage IV was identified, any drainage is noted, physician to be notified and consider a culture and sensitivity. The LN will assess residents for pain related to the pressure ulcer treatment. The National Pressure Ulcer Advisory Panel (NPUAP) indicated that assessment and treatment of [REDACTED]. Each existing pressure ulcer be identified, whether present on admission or developed after admission, and that factors that influenced its development, the potential for development of additional ulcers or for the deterioration of the pressure ulcer(s) be recognized, assessed and addressed. When assessing the ulcer itself, it is important to: -Differentiate the type of ulcer (pressure-related versus non-pressure-related) because interventions may vary depending on the specific type of ulcer; -Determine the ulcer's stage; -Describe and monitor the ulcer's characteristics; -Monitor the progress toward healing and for potential complications; -Determine if infection is present; -Assess, treat and monitor pain. Pain that interferes with movement and/or affects mood may contribute to immobility and contribute to the potential for developing a pressure ulcer or for delayed healing or non-healing of an already existing ulcer. Resident 1's record indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 was able to make health care decisions for herself. Resident 1's skin assessments from the hospital, dated 4/9/14 at 7 am and at 7 pm, the coccyx area was clear of any wound or red areas. The admission resident assessment dated [DATE], the skin condition indicated it was pinkish red and excoriated at the coccyx area (reddened skin at the tailbone). The form instructed to indicate size, depth, color and drainage but there were no measurements for the identified coccyx area. The bowel and bladder evaluation described Resident 1 had incontinent (unable to hold urine) episodes of urine and was constipated. During a concurrent interview and record review on 2/4/15 at 2:44 pm, with the Director of Nursing (DON) and Licensed Nurse (LN) A who is also the Minimum Data Set (a resident assessment) coordinator. The DON and LN A confirmed further assessment was needed to determine pressure versus non-pressure wound. The DON nor the LN A was able to find documentation that a LN assessed the coccyx area by pressing on the wound to determine if the skin was blanchable or non-blanchable and if pain was present when pressure was applied. The DON and LN A both agreed the description of red over the coccyx and that the two areas of hardness/induration was a Stage I pressure ulcer. During an interview on 02/12/15 at 10:15 am, LN C stated the initial admission assessment of Resident 1 indicated a pinkish and red excoriated area around the coccyx. LN C further explained she did not press or touch the wound to determine if it was a pressure versus non-pressure wound. LN C's initial assessment was sight only and did not identify this as a Stage I pressure wound. There was no documentation found in the record that the physician was notified of Resident 1's pinkish red and excoriated coccyx. A skin treatment order was written on 4/13/14 to apply Zinc Oxide (used to prevent diaper rash) to the coccyx excoriation, three days after the coccyx wound was identified. The Norton Plus Pressure Ulcer scale (a tool used by the facility for estimating resident's risk for developing a pressure ulcer) dated 4/14/14 indicated a risk score of 12, which put the resident at a moderate risk for developing a pressure ulcer. Upon further review of the entries of mobility and incontinence, the score was indicating Resident 1's mobility as slightly limited and occasional incontinence. The record reflected her mobility was very limited and usually incontinent of urine, which would bring her Norton scale to a high risk score. During an interview on 2/4/15 at 2:44 pm, the LN A stated the Norton Plus Pressure Ulcer Scale was not assessed correctly and that Resident 4 was at a high risk for developing a pressure ulcer. The skin condition record of coccyx assessments were as follows: 4/12/14- no length and width, wound bed excoriated red with surrounding tissue/wound edges red. No assessment of pain related to the wound. 4/15/14- no length and width, wound bed red/pink surrounding tissue/wound within normal limits. No assessment of pain related to the wound. Progress improved. 4/22/14- no length and width, wound bed red surrounding tissue within normal limits. No assessment of pain related to the wound. Progress deteriorated. Physician was not notified until four days later 4/26/14. 4/26/14- Stage II (partial thickness loss of outerlayer skin open ulcer with a red pink wound bed) , size 7.5 centimeters (cm) by 6 cm undermining (separation of tissue from the surface) tissue of 0.2 cm. The skin surrounding the wound was pink/bright red. Pain with pressure was severe sharp pain. Physician notified new orders. 4/29/14-Unstageable (Full-tissue thickness loss where the base of the ulcer is covered by dead tissue), size 7.5 cm by 6 cm, an undetermined depth. The skin surrounding the wound was pink and bright red. No assessment of pain related to the wound. The nurse's notes were as follows: 4/13/14- Coccyx excoriation has increased, new order for zinc oxide every shift and as needed for incontinence. 4/16/14-Excoriations on buttocks continue to worsen, Medical Doctor(MD) faxed. New wound care orders on 4/22/14, six days later and 12 days after initial skin assessment. 4/17-4/25/14-No nursing assessments of coccyx were found in notes. 4/26/14- Stage II pressure ulcer bilateral buttock/coccyx. New orders for wound care, a low air loss mattress and a Foley catheter. 4/29/14-Bilateral buttock coccyx area with slough, peri-wound remains red/pink. Redness around open area is hard to touch as the wound bed was prior to becoming open. 4/30/14- New orders for supplements Vitamin C and Zinc Sulfate. 4/30-5/2/14-No coccyx wound notes found in nurse ' s notes. 5/2/14- Sharp debridement (removal dead tissue) to sacral coccyx area tunneling 4.3 cm purulent (pus) drainage with foul odor (sign of infection), wound bed sloughing (remove dead skin), the surrounding tissue remains hard to touch and causing pain. Resident initially admitted with large area of redness and induration to area. No indication of pre-medicating for pain before the procedure. A new physician order [REDACTED]. 5/3-5/5/14- No further nursing notes about coccyx wound and Resident 1 was transported to hospital on [DATE] for feeling poorly, she stated something's wrong. The care plan titled Altered Skin Integrity related to Pressure dated 4/14/14, indicated an excoriation with two areas of hardness. Under pressure reduction, the low air loss mattress was initiated on 4/29/14, seven days after it was noted in the skin assessments that the wound had deteriorated. The pressure reduction cushion was not implemented. The interventions selected were to monitor the skin wound for worsening, pain, and signs and symptoms of infection. The IDT meeting notes dated 4/24/14 indicated that there was no discussion related to skin integrity problems. The next IDT note dated 5/1/14 one week later, had a skin review that identified Resident 1 was admitted with red excoriation to coccyx with areas of hardness. No new orders or interventions resulted from this IDT meeting. There was no record of physician notification of purulent drainage and the foul odor identified on 5/2/14 by nursing staff or that a wound culture was done per facility policy. During a concurrent interview and record review on 2/4/15 at 2:44 pm, with the DON, SS and LN A was conducted. The LN A stated the wound/treatment care nurse was no longer an employee. The SS stated Resident 1 was non-compliant (refused care). The DON, SS, and LN A were unable to find documentation that showed any refusal of care. The DON confirmed the wound and skin management policy was not followed when physician was not notified timely of wound deterioration. During an interview on 2/10/15 at 12 pm, the Physical Therapist (PT) B stated he performed a one time sharp debridement on 5/2/14 of Resident 1's pressure wound which he described as a Stage II with grey/yellow slough (dead tissue). PT B stated once he opened the wound it had tunneling and the depth reached the sacrum. PT B further explained that there was a purulent foul smelling drainage which indicated infection. PT B did not notify the physician, though he made a referral to nursing service to request a wound specialist consultation due to the determination of a Stage IV with depth reaching to the sacrum. PT B could not find a record of a wound culture result nor that a wound specialist consult had been done. PT B stated that Resident 1 had chronic episodes of diarrhea which delayed her therapy progress and would have contributed to the progression of her pressure wound. The acute hospital records were reviewed for Resident 1's admission on 5/5/14. The initial laboratory tests indicated Resident 1 had an elevated white count (indicates infection), BUN and creatnine (test for hydration and kidney function) were acutely (critical) elevated indicating dehydration (not enough fluid in body.) The reason for hospital admit was for acute [MEDICAL CONDITION] (kidneys not working) due to nausea/vomit and acute Stage IV pressure ulcer. Resident 1 received wound care, antibiotic therapy and hydration. Resident 1's coccyx wound was then surgically debrided during her hospital stay and then discharged with a [DEVICE] to another skilled facility for wound care.

Based on interview and record review the facility failed to ensure that one resident (Resident 1) received sufficient fluid needed to prevent dehydration (not enough fluid in body). The changing fluids needs for Resident 1 were not addressed after episodes of nausea, vomiting and diarrhea. These failures resulted in a hospitalization related to acute [MEDICAL CONDITION] due to dehydration and were contributing factors in the Stage IV pressure ulcer development. Refer to F 314. Findings: Resident 1's record indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 was able to make health care decisions for herself. The initial potential fluid volume deficit assessment (fluid given during hospital stay leaves body) dated 4/14/14 identified Resident 1 as a low risk. There were no further assessments documented. The Intake and Output record was started on 4/10/14 and was discontinued on 4/13/14. The average 24 hour intake was reported at 1059 milliliters (ml). The Registered Dietician (RD) nutrition assessment dated [DATE] evaluated the fluids needs for Resident 1 as 2382 ml a day. Resident 1's had a physicians order dated 4/10/14, [MEDICATION NAME] (water pill to reduce fluid in body) 40 milligrams by mouth twice a day for [MEDICAL CONDITION] (swelling). [MEDICATION NAME] has a side effect of dehydration. The nutritional progress notes read as follows: 4/15/14-Weight down 3.4 three days after admit. Potential for weight loss related to fluid equalization. 4/16/14-Weight loss expected with fluid equalization. 4/22/14- Nausea and vomiting may be related to [MEDICAL CONDITION]. Potential for weight loss related to fluid equalization. 4/29/14- Emesis (vomiting) on 4/28/14 and nausea may be related to [MEDICAL CONDITION]. Potential for weight loss related to fluid equalization. 5/1/14- Has had nausea. No changes or reassessments related to fluid needs found in the nutritional record. During an interview on 2/17/15 at 11 am, the Registered Dietician (RD) stated fluid equalization should resolve in the first week after discharge. The RD stated Resident 1 had a weight loss of 8.8 pounds over a period of 19 days and it was all fluid loss. The RD does not attend the Interdisciplinary team (IDT, responsible for discussing resident specific care needs) meetings. The RD stated nursing services was aware of the nausea and vomiting issue and that the MD was notified. The RD stated nursing services would need to contact her if the fluids needs required reassessment. The care plan for risk for fluid volume deficit dated 4/14/14 had interventions which included monitor intake and output and monitor side effects of medication. The care plan was not updated to include risk factors of diarrhea, poor PO intake, and nutritional compromise. The nurse's notes read as follows: 4/17/14- Emesis one time and loose stool two times. Medical Director (MD) notified. 4/20/14- Two episodes diarrhea. 4/24/14 - Lightheaded and poor balance. 4/25/14- One episode diarrhea. 4/28/14-One episode nausea/vomit. MD notified. 4/29/14-New order for [MEDICATION NAME] 4 milligrams by mouth every four hours as needed for nausea. 5/4/14- at 1 pm Large emesis. MD notified 5/4/14- at 10 pm Emesis four times. [MEDICATION NAME] given. MD notified. Foley draining dark yellow urine. 5/5/14- at 9:55 am Nausea. [MEDICATION NAME] given. 5/5/14- at 12:40 pm Large emesis, increased lethargy and decreased level of consciousness. MD notified sent to hospital. The nursing notes did not include any assessments related to [MEDICAL CONDITION] which would indicate fluid overload. The physician notifications were as follows: 4/17/14- Resident had emesis by one and loose stool two times. No new orders. 4/23/14-Resident had two episodes of emesis, am and pm shift. No new orders. 4/28/14-Resident is frequently nauseated and emesis daily. Order received for [MEDICATION NAME]. 5/4/14-Resident had episode of emesis. No new orders. There were no records found that indicated the physician was aware of the other episodes of diarrhea found in the record for 4/20/14 and 4/25/14. The facility policy titled Hydration Program release date 9/1/2008 assured the facility will provide each resident with sufficient fluid intake to maintain proper hydration and health. IDT will assess residents' hydration status on admission, quarterly, annually, and as needed. Licensed Nurses (LN) will document hydration status at least weekly in the nursing notes. The facility policy titled Intake and Output release date 9/1/2008 indicated the LN shall consider intake and output which included urinary catheter, vomiting and diarrhea which persists and those identified at risk of dehydration. The LN nurse shall review and document a review at least weekly to assess the resident's fluid status and determine if still required. A Foley catheter (a tube in bladder to drain urine) was placed on 4/28/14 per physician order [REDACTED]. Resident 1 was not placed on intake and output evaluations. During an interview on 2/4/15 at 2:44 pm, LN A stated Resident should have been placed on intake and output monitoring due to the multiple episodes of nausea/vomiting and diarrhea and when the Foley catheter was placed. LN A confirmed the Intake and Output policy was not followed. LN A further explained she recalled Resident 1 had issues with nausea and vomiting the entire time while at the facility. The weekly nursing summaries did not have an assessment area which addressed hydration needs. The nurse's notes did not include any assessments related to Resident 1's hydration status to ensure the RD fluid intake recommendation of 2382 ml a day was met or not met. The IDT notes dated 4/24/14 indicated Resident 1's laboratory results for Creatinine (lab value measures kidney function) was 3.03 a high level which can indicate dehydration. There was no IDT documentation about monitoring of the intake and output of Resident 1 to determine if the fluid goals or calculated fluid needs were met consistently. The IDT notes did not include documentation about the frequent episodes of nausea/vomiting and diarrhea. During an interview on 2/10/15 at 12 pm, Physical Therapist (PT) B described Resident 1 was having chronic diarrhea which delayed her therapy progress and pressure wound healing. PT B further explained Resident 1 was tired and lightheaded at times during therapy sessions. According to the Mayo Clinic Diseases and conditions Dehydration dated 2/12/14, older adults and people with chronic illnesses are most at risk, such as kidney disease. Medications such as diuretics, can also put people at risk. The signs and symptoms of dehydration include nausea and vomiting, lightheadedness, weakness, and decreased urine output. This can result in kidney failure, potentially life-threatening problem occurs when your kidneys are no longer able to remove excess fluids and waste from your blood. The acute hospital records were reviewed for Resident 1's admission on 5/5/14. The initial laboratory tests indicated Resident 1 had an elevated white count (indicates infection), BUN and creatinine (test for hydration and kidney function) were acutely (critical) elevated indicating dehydration. The reason for hospital admit was for acute [MEDICAL CONDITION] (kidneys not working cleaning blood) due to nausea/vomit and acute Stage IV pressure ulcer. Resident 1 received wound care, antibiotic therapy and hydration. Resident 1's coccyx wound was then surgically debrided during her hospital stay and then discharged with a [DEVICE] to another skilled facility for wound care.